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OBSTETRICAL   TRANSACTIONS. 

VOL.    XXXII. 


SsatTBO  Bt   muss  AXD  BON,  BABXHOLOIEXW  CLOiS. 


OBSTETRICAL  SOCIETY   OP  LONDON. 


OPPrCERS   FOR    1891. 
Elkctbd  PKBNVA.nr  Itk,  1B91. 


FtnetDBTT- 


TICB- 
PBRSTUKNTa. 


THBiBURER. 

CHAiaUjtN  or 

TtlE  DOARO  rOB. 

TUKEXAUtKATION 

or  lUDWtVU. 

HOKOUASr 

BECBETABIKS. 

flOVORAKT 

LIBBXBIAS. 


SOVOBAST 

HBUBUa 

or  OOCHCIL. 


OTHER 

UElfBERS 

OP  OOVHCU. 


BLACK.  JAMES  WATT,  M.A.,  M.D. 
fBOULTON,  PERCY,  M.D. 

COKKT,  THOS.  C.  HTEUART.  M.D,  (Bdiwt). 
J  HAVES,  THOMAS  CKAWFOKD,  M.A.,  M.D. 
]  JO>'K8,  EVAN  CAberdare). 

MEKEDFTH.  WM.  APPLETON,  M.B.,  CM. 
LTAPSON,  ALERED  JOSEPH,  M.B. 

REHMAN.  G.  ERNEST.  M.B. 

L  CMAMPNETS,FBANC18HENEY.M.A.,M.D. 

r  DOBAN,  ALBAN. 

I  HORROCKS,  PETER,  M.D. 

}.  DUNCAN,  TnLLlAM,  M.D. 

OLDHAM,  HENllY,  M.D.  CZV«.(«). 

BARNES,  ROBERT,  M.D.  (ZVw/«). 

HEWITT.  ORAILY,  M.D. 

HICKS.  JOHN  BBAi'TON,  M.D..  P.H.8. 

TILT,  EDWAED  JOHN,  M.D. 

PRIESTLEY,  WILLIAM  O.,  M.D. 

WEST,  CHARLES,  M.D. 

QALABIN,  ALFRED  LEWIS,  M.A.,  M.D. 
I.  WELLS, Sia THOS.  SPENCER,  Bart.  {Trustee). 

BUrLER-SMYTHE.  A.  C. 

CO.\TE8,  FRED.  WM.,  M.D.  (Sftliitbiiry). 

CtJLLINGWOUTH,  CHARLES  .lAMES,  M.D. 

DAK'IN.  W.  RADFORD,  M.D. 

DAVSON,  N,  UOITSTON,  M.D. 

FREEMAN,  HENRY  W.  (Bath). 

GALTON,  JOHN  H..  MJ). 

GERVIS,  HENRY,  M.D. 

HEATH,  WILLIAM  LENTON,  M.D. 

JOHNSTON.  JOSEPH.  M.D. 

LEDIARD,  HENRY  A.,  M.D.  (CarlUle). 

M.\RCH.  HENRY  COLLEY,  M.D.  CBochUale). 

NESHAM.  T.  C.  M.D.  (NewcaBtlo-on-Triie). 

PHILLIPS,  G.  R.  TURNER. 

PHILPOT,  JOSEPH  HENRY,  M.D. 

POTTER,  JOHN  BAPTISTE.  M.D. 

3PENCER,  HERBERT  B..  M.D. 
LWEBB.  HARRY  SPEAKMAN  (Welwjn). 


STANDING   COMMITTEES. 


BOARD  FOR  THE  EXAMINATION  OF  MIDWLVES. 


ca\iBH.iK.      CHAMPNETS.FaANClSnENliY,M.A.,M.D. 
BDULTON.  rEltCT,  M.D. 
BOXALL,  ROBERT.  M.U. 
OULLINWWORTH,  CHARLES  JAMES,  MD. 
(•BLACK.  J.   WATT,  AJ.A.,  M.D.,  PresiJcni. 
tx.orFicio.J  DORAN.  ALBAN.  )  „      o 

(HORROCKS,  PETEB>  M.D.  J  ^'"'- ***'■ 


LIBRARY  COMMITTEE. 


tx-oprrcio 


CHAMPNErs.  FRANCIS  HENRY,  M.A.,M.I>. 
OALABIN,  ALFRED  LEWIS,  M.A.,  M.D. 
HEWITT,  GRAILT,  M.D. 
PHILLIPS,  JOHN.  M.D. 
fBLACK.  J.  WATT,  M.A..  M.D.,  J^retidmtt. 
HERMAN,  a.    ERNEST,  M.B.,  l^eamrer. 
.4  DORAN.  ALBAN,  }  rr       q 

IlOIiROCKS.  PETER.  M.D..  J  """■  ^^'"''■ 
DUNCAN,  WILLIAM,  M.D.,  Stm.  Lib. 


PUBLICATION   COMMIITEE. 


GERTIS.  HENRY,  M.D. 

HERMAN,  G.  ERNEST,  M.B. 

HEWITT,  GRAILY,  M.D. 

FLAYi'AIR,  WILLIAM   S.,  M.D. 

POrrKR,  JOHN  BAPTISTB,  M.D. 

WILLIAMS,  JOHN,  M.D. 
fBLACK,  J,  WATT,  M.A.,  M.D,,  PretiJtnt. 

CHAMPNEYt*.  FRANClaHENBY>M.A.,M.D., 
KZ-OFFICIO.  <       Ediior. 

DOKAN,  ALBAN.  5  „      „ 

(.HORROCKS,  PETER,  M.D..  j  ■"*"•  *■*'■ 


HONORARY  LOCAL  SECRETARIES. 


JowsB,  Etan Aberdtw. 

Goss,  T.  BiDUULFH  Bath. 

Shaepin,  Henby  W. Bedford. 

Corky,  THOMA9  C.  S.,  M.D Belfast. 

Malins,  EswAUD,  M.D. BirmingliAW. 

FURNER,  WlLLOUOHBY  .        >      B^gllton. 

SALZMANN,  FttEDElllCK  WILLIAM     )  * 

Swathe,  Joshi-h  Guifpitiis,  M.D.    Brietol. 

Lowe,  Oeokge Burton-on-Trent. 

RiODEN,  Geobge Canterbury. 

Lawiienck,  a.  E.  Aust,  M.D Clil'ton, 

FiTzoEBAiB.  Chakiks  Eoertok,  M.D. Folkestone. 

BnAiruwAiTE,  James,  M.D Leeds. 

Wallace,  John,  M,D. Liverpool, 

TaosiFsoN,  Joseph   Nottinghnin, 

Walker,  Thomas  Jameb,  M.D PetcrhorougU. 

Waltbhs.  James  HoPKiNa  Eeadiog, 

CoATEs,  FitEBcidCK  William,  M.D Salisbury. 

WusoK,  RoBEiir  James  St-LeoiiardV 

TAVtOB,  JoHM  W.,  M.D. Scarborough. 

Keehnq,  James  Huiid,  M.D Slieffield. 

Bdrd,  Edward,  M.D.,  CM Slirew«tiiiry. 

Chilub,  Cbkistopher,  M.D Weymoutli. 

Haekis,  William  John   Worthing. 

IIabvbv,  Robert,  M.D Calcutta. 

nRABFOOT,  Arthur  MuDBE,  M.B Madras. 

Pehhioo,  Jaubs,  M.D Montreal,  Canadn. 

ANDBB80N,  Uett  W.,  M.D Jamaica. 

Takasi,  Kanarsiro JapAR. 


OBSTETRICAL  SOCIETY  OF  LONDON. 


TBCSTfKS  OP  tBB   SOCIETY'S   PEOrBRTY. 
HcNBV  Oldham,  M.D. 

ROBEBT  BlBNEa,  M.O. 

Sir  Tbomas  SfGNcER  Wells,  Uate. 


HONORARY  FELLOWS. 

HBITllill    SUBJECT)!. 

Ejected 

1871  Kbillbb,  Aleilikdeo,  M.D.,  F,R.S.  Ed.,  Pljyalciou  to  tbc 
RoyaJ  Mntrmity  Hospitn,!,  L^ciurer  on  Midwirvry  and 
DiataacB  of  Women  and  Ctuldrtii  at  Surgeons'  lUll, 
Ediuburgh  ;  21,  Qtieeo  Blrcct.  Edinburgli. 

1871  KiDO,  Gxouge  H.,  M.D.,  F.R.C.S.I.,  Ob*<tetriciil  Surgeon 
to  the  Coombe  Lying-in  Iloipilnl;  30,  Merrion  ti;|unr« 
sonth,  DubLin. 

1870  West,  Chables,  M.P.,  F.K.C.P,,  Foreign  A»ociatc  of 
ih«  Academy  of  Medicine  of  Parin  ;  55,  Uftrie/  street, 
W.     Fret.  1877-8. 


FOBJIQK  atJBJEOTS. 

1873  Bahkes,  Fokdycb,  U.D.,  Professor  of  Clinical  MidwifeT; 
and  DieeaseH  of  'Women  at  tbe  Bellevue  Uospitat 
>Iedical  College,  and  Obstetric  Pbyiician  to  tbe  Bellevoe 
Hoapitsl ;  S&,  Madieon  avenue,  New  York. 


^H 

PELLOW3    OP    THB                                                   ^^^^^^^^^| 

^^^H          Slecteil                                                                                                    ^^^^1 

^H         1&63 

£li&CM  VON  F£iUNWALi>,  Ci&L,  M.O.,  Fraf«t8or  of  Midwirery, 

^^B 

Vienna. 

^H         1866 

HBGBSBERor.R,  Theodor,   M,D.,  k  la  Maternite,  et  aux 

^^M 

Enfant*  Trouv^s  ;  HfipitHl  ^es  AccouclieinenU,  Moscot. 

^H^isee 

LlSAUE WITCH,  J.,  M.B.,  Proreasor  Emmtus  and  Physician 

^^^^L 

to  tlie  Mnximiliiin   Hoopttnl ;  Spnekaja,  2,  St.  Fttera- 

^^^^F 

burg.     Trana.  3. 

^H 

Pajot,  Cir.  M.D.,  late  Professor  of  Midwifery  to  the  Faculty 

^^1 

of  Medi<!iiie,  PiuHr. 

^H         I8A2 

ScAKSOMir  F.  W.  TON,  M.D.,  Wiiniburg.                               ^^^^ 

^H         1877 

Stoltz,  Profcsdor,  M.D.   Naucy,                                                ^^^B 

^^^^  1891 

Tabnibr,  St^fhane,  M.D.,  ProfeMor  of  ObBtetrics,  Faculty         H 

^^^^^ 

de  M^decine  de  Parii.                                                                   H 

^^^^1873 

Thohas,  T.  GATJxtARD,  M.D.,  ProfeBBor  of  Obstetrics  in  lh«          H 

^^^^^ 

College    of    Physicians    and    Surjeuiis  ;    296,    Fifth          H 

^^^^h 

avenue,  New  York,                                                                        H 

^^^^^1862 

ViBoitow,  RuDOLr,  M.D.,  Profeisor  of  Pathological  Ana-         H 

K 

„.....-..,„.          ^ 

H 

CORRESPONDING    FELLOWS. 

^^^^187.3 

Mabtin,  a.  E,,  M.D.,  Berlin,     TVaM.  I. 

^H         1876 

BtBiN-,    P.,    M.D.,    12!f,    Boulevard    St.    GerL^kain,    Paris. 

^H 

Traw.  i. 

^H        1676 

Cdadwiok,  James  R.,  M,A.,  M.D.,  Physirian  far  DUfaae* 

^^^^^ 

of  Women,  Boatou   City  Hospital;    ClareDdon  street, 

^^^^v 

Hoaion.  MassnrlinBetts,  U.S. 

^■~1877 

GoODE!.L,  William,  A.M.,  M.D.,  ProfeBsor  of  Gynecology 

^^^^^ 

ill    tlie    Uni  verity    oF  Pennsylflnnin  ;    1418,    Spruce 

^^^^P 

street,  PbiUdeiphia,  PeiiiiHytvania. 

B              187« 

LnsK,  WiitTAU  Thomtson,  M.D.,  Profesior  of  Obstetrica, 

^H 

Ilellevue  Hoiipiint  Medical  College;  New  York. 

^^        1877 

Stobbr,  Horatio  K.,  M.D.,  Newport,  Hhode  Island,  U.S.A, 

ORDINARY     fellows: 
1891. 


Tlio«e  iiiirk«l  tbiu  (*}  have  paid  the  Compot'ition  Fm  in  lien  ot  further 

■DOunl  lubicrtpliniit. 

flw  UU«n  O.P.  uc  praAxcd  to  the  atnttt»»t  tin;  "OriginU  Fellan"  a(  the 

Socletv. 


Sleeted 

1887  AoaiKD,  ALBXANnBB  Louis,  M.D.,  10,  Blandford  street, 
Portmaii  square,  W. 

1690  AcKr.Ri.EY,  Rioni.BD,  M.B.,  fi.S.Oion.,  Alexandra  House, 
Aalifaurton,  Devon. 

iS8i  Adahi,  Thomas  Rvthkr[>deu,  M.D.,  Stamford  Home,  78, 
St.  Jamea's  rond,  Croydon. 

1S90  Al>Dl»sBLL,  AuousTL's  W.,  M.B.,  C.M.Edin.,  30,  Asbbun 
place,  South  Kenaingtou,  S.W, 

1863  All&k,  Robert  Jokn,  L.R.C.P.Ed.,  The  Glen,  Sammer 
bill,  Sydney,  New  South  Wnlcs.  [Per  Alcxaudcr 
Allan,  Esq.,  Glen  House,  The  Ynlley,  Scarborough.] 

1890  Allax,  Thomas  E.,  L.R.C.P.  &  S.Ed.,  7,  S&lford  t«rrac«, 
Tonbridgc. 

1873  AJXiDt,  Hbnki  Makcus.  P.B.C.P.  Ed.,  20,  EUgencj' 
square,  Briglitou. 

1SB7  AUBKOSK.  RoBEST,  B.A.,  L.R.C.P.  &  S.£d.,  1.  Mount  place, 
Wbitcehapel  road,  E. 

1878  AUDEBsoy,  Iterr  William,  M.D,,  95,  Duke  street,  Kings- 
ton, Jamaicn.     Tra»».  1.     Qon.  toe.  See. 

1875  ANDBBaoN,  JouH  Font),  M.D.,  O.M.,  I,  BuckUnd  crescent, 
BeUii*  park,  N.W.      Cwnt^,  1882. 


Xl» 


rXLLOWB    or   THK    HOLIKTIT. 


ISfi€*  Akdbbws,   IIknry  Charles,   M.D.,    II,  Addlion  tcrrac^ 
Nolting  hill,  W.     CokmciV,  IS82.3. 

1859     AKoaRws,  J.^mrh,  M.D.,  Eirerleigh,  Green  hill,  HampBtead, 
N.W.     Cmncil.  18SI. 

188B     Amnaokbr.    Eunbht,  M.D.,   Berlin,    292,  Oxrord    roftd, 
5I«nc  heater. 

1690  Ansok,  Okqkgr  Edwahd,  M.A.,  M.D.Cantab.,  St.  Thomas's 
HDvpital,  8.E. 

IHS-I  Appleford,  Stephen  Herbrrt,  L.R.C.P.  Lond.,  17,  Fins- 
bnry  ctrciia,  E.C. 

1870  Appleton,  Robert  Cakuale,  The  Bur  Houie,  Beverley. 
1884     Applbtos,  Tuouab  A.,  46,  Britanniii  road.  Fulham,  8.W. 
1883     Archibald,  John,  M.D.,  Wooilhouo*  Ehvm,  Lough  borough . 

1871  Arqi.£s,  Frank,  L.K,G.P.  Bi).,  Hennon  Lodge,  Wansleid, 

Eases.  N.E.     Cau/jciV,  l88ti-7. 

1888  Abmsthono,  Jahes,  M.B.  Edin..  84,  !Rodn«y  itreet,  Liver- 
pool. 

1886  Ashe,  \VtLLt.(.M  Psrct,  L.R.C.P.  Lond.,  I17  Bank,  Cbiile- 

hurst. 

O.P.  AvKLiKU,  Jakb&  H.,  M.D.,  Coniulting  Pliyeiciao  to  the 
Ciiclstn  Hwpilal  for  Women  j  1,  Upper  Wimpole 
Btreet,  W.  Couneit,  1865.66,  1872,  1884.  Sm.  &«. 
1878.  Hon.  Lib.  \ 87 A-6.  Vice-Pr««.  \S77-S.  Board 
Exam.  Midwiett,  1S"2,  \^'b-77.  Chairman,  1879-83. 
Tram.  'J. 

1872  AvUNo.  Arthur  H.  W.,  94a,  Ore&t  Porllnud  street,  W. 

1887  Bailry,  Henry  KReneRicK,  Tlie  Holliei,  Le«  terrace,  L««. 

S.B. 

IS87  Bakbk,  Osualu,  L.R.C.P.&S.  Ed.,  Surgeon- Major,  Indiui 
Army,  Simla,  India. 

1880  Balls- Head  LET,  Walter,  M.D.,  F.B.C.P.,  5,  Collina  street 
efl»t,  Meiboitrne,  Ticloria. 

1869*  BaNiook,  Osokor  Oba»villb,  M.D.,  Sui^on  to  the 
Samaritan  Free  HnipitA] ;  12,  Qranville  pUct,  Porttuaa 
tquare,  W.     CouneU,  1874-6.     Tram.  2. 


PILLOWS    OF    THE    SOCIITT. 


XT 


Eleoled 

1866*  Babboub,  a,  H.  Fbbblamd,  M.D.  Edin.,  24,  MetTille  street, 
Ediobiirgb. 

O.P.  BiEKBs,  RoBBBT,  M.D.,  F.R.C.P.,  Coniulling  Obstetric 
Physicinti  to  St.  George's  HoBpimli  15,  Hurley  Mrcct, 
Caveadish  iqunrc,  W.  Vice-Prfe.  1859-60.  Council, 
1861-62,  1867.  Tr«M.  1S63-64.  Prft.  t8e5'66. 
Trmt.  32.     TrH$tfe. 

1878  BiBKF,9,  R.  S.  Kancoubt,  M.D.,  Physician  to  tie  CIipIm* 
HoBpital  for  Women  ;  7,  Quceu  Aniic  street,  CafcudiBli 
Miuare,  W.  Council,  1H79-81.  Board  Exam.  Mid- 
wiv<«,  1880-2.     Trant.  2. 

1877     Barnes, Thomas  Hrkbv,  M.D.,  105,  LnndonTcsd,  Crnydon, 

186<1  BAHKAOLOceu,  Rubkht  W.  8.,  M.D.,  M.  Dulwich  roftd, 
HeroebiU,  8.\V, 

1687    Bahtom,  Hbnbt  Tiiouas,  £3,  Harford  atreet,  E. 

1887  Baktom,  WiLiiAH  BoffiK,  L,K.C.P.  Lond.,  Stnunton-oii- 
Wjre,  near  Hereford. 

1861*  Bahtium,  Jonw  S.,  F.K.C.S.,  Snrgeou  to  the  Bntli  General 
Hospital  1   13,  6iy  street,  Bath.     Council,  1877-9. 

I8W  BaBSBTT,  JoDy,  M.D.,l'rofesaorof  Midwifery  nt  the  Queen's 
College,  Binningham  ;  1-14,  Hockley  bill,  Birmingham. 
Council,  187-1-6.     FiM-Pret.  ISSO-2.     IVffn#.  3. 

Bate,  Geokoe  Paddock,  M.D.,  41'^,  Berbual  On-en  road, 
N.B, ;  and  2,  North  it  mbfrlnnd  lloiiHca,  King  Edward 
road,  lUckiiey.     Covneil,  1882-4. 

1687  Ba(;hoabtkeb,  Hznuv  Sp£LHAN,  M.B.  Durb..  Saville 
plaw,  Newcftiile-oa-Tjne. 

1671  BiEAOH,  Fletcubu,  M.B.,  F.R.C.P.,  Darenth  Asylum,  Dart- 
ford,  Kttit. 

1871  Bkadles,  AKTiiUB,  Park  Honse,  Dartmouth  Park,  Forest 
biU,  S.E. 

leSfr    BsATTV,  William  Joiui,  LK.C.F.  Ed.,  Stock ton-on -Tees. 

1866*  BBLcnRR,  Hekby,  M.D.,  28,  Cromwell rund,  West  Brtgbloil. 


m 


rsLLows  or  thb  society. 


1871  Bkll,  Robert,  \f.I>.  Glasg.,  29,  Lynedoch  street,  Olaigaw. 

1880  Beminoton,  Robebt  Crewdson,  M.B.,  59,  Osborue  Bead. 
NewcA8H«>on-Tyne. 

1873*  Bknxst,  Jauss  Hbnht,  M.D.,  Mentone.  CotiiieiV,  1881*3. 
Tratu.  I. 

188!)  Bemsok,  MA.TTHEW,  M.D.Brux.)  35,  Dicconion  atreet, 
Wigan. 

1683  Bbrtolacci,  J.  Hewbtsok,  care  ^t'  Dr.  March,  Woodlawn, 
Spencrr  park,  New  Wnndawortb,  S.W. 

1889     Best,  William  James,  1,  Cwnbridge  terrace,  DoTer. 

1887     Beswick,  JtoBERT,  161,  BiehopBgRte  street  Witbout,  E.G. 

1691  Beviile,  Frbdehick  Wells,  L.B.C.F.Lond.,  The  Pin, 
Palace  rond,  Baat  Molcaey, 

1887     BiDKH,  GujLRLBS  Waltbh,  L.K.C.P.Lond.,  Laxfield,  Fram- 

liugliam. 

1879     BioQS,  J.  M..  Hillaide,  Child'a  liiU,  N.W. 

1889  BiaaiiQPP,     Fhanci3      Robert     Bur  ant.     M.A.,     M.B., 

B.C.Contnb.,   Belvedere,  Mount   Flcaiiiiit,  Tiiabiidge 
WelU. 

1890  Black,  George,  M.B.,   B.S.LoDd.,  50,  CazeDo?e    rotd, 

Stamford  hill,  N. 

1868*  BiAOK,  James  Watt,  M.A.,  M.D.,  Obstetric  PttyBician  to  the 
Clianiig  CrasB  Hospital ;  15,  Clftrges  street,  Piccadilly, 
W.  Couneii,  18;2-4.  Vice-Prea.  18«5-6.  Chairman, 
Board  Exam.  Midwioea,  1887-90.     Pra.  1891. 

1861*  Blake,  Thomas  Wiujah,  Huretbourne,  Bournemoutb, 
UanU. 

1872  Blanu,  GEonGE,   Surgeon  to  the   MaccleafleLd  Infirmary 

Park  Green,  Macclesfield. 

1887     Bluett,  Obokqe  Maliack,  L.H.C.P.  Lond.,  3,  Priory  road, 

Bedford  park,  Chiawick. 

1883  BoKNEY,  William  Acau»Tii9,  M.D.,  U5,  Beaufort  ttreet, 
Clielien,  S.W. 


PCLLOWt   or   THB   SOOIKTV. 


xni 


EUcted 

1866*   BOOLTOM,  Pebcv,  M.D.,  PhysiciAa  to  th«  S&msriUn   Five 

Ilospiul,    li,    Sryinoiir    Ntreet,    Purtmnn    iqiiare,   W, 

Council.  187ft-80,  18S5.     Hon.  Lib.  18SG.     ffon.  See. 

18**6.9.    Fii:e-Pret.  [890-9\.    Board  Exam.  Slidwiwt, 

1890-91.     Trans.  A. 
1886    BorsTEAU,  Roaissow,  M.D,,  Snrgeon- Major.  Indian  Army, 

c/o  Messrs.  H.  S.  King  nud  Co..  45.  PnM  MnlJ.  S.W. 
1877     BowKETT,  TnouAR  Edwahd,  11.^,  East  In  din  road,  Poplar, 

B.     Council,  1890. 
1884*  BoXALL,  TtoBEKT,  M.D.,  AMtslnnt  Obslelric  PlijrsidHQ   tu, 

and  liCctiiTPr  on  Practical  Midwifery  at,  the  Middlesex 

noapital;    6,  GlinnJns  street,  Caveadi»li  square,   W, 

Council,    I8S8-&0.      Board    Exam.    Midmvet,    1891. 

Tram.  10. 

18911    Boycott,  Abthur   Koshak,    L.B.C.F.  Lond.,  Cane  hill, 
Ptirlpy,  Surrey. 

I6B4     BoTs,  Abtbub  Henbv,  L.R.C.P.Qd.,  Cliequer  Lnvu,  St. 

Aiban<. 
1S86    BBAOBDRr,  Hahyby  K.,  7,  Horninglov  etrcctj  Barton-on- 

Tfcnt. 

1877     BRA.DLET,  Michael  McWiluams,  M.B.,  jBrrow-on-Tyn*, 

1873  BBAiTnwAiTE,  JaU£3.  M.P.,  Obctetric  Pliyncian  to  (be 
Leed*  General  [nlipmary ;  L^oturer  on  Disi>aHe»  of 
WonwD  and  Cliildrrn  xt  itie  he^A»  ficliool  of  Medicine  [ 
16.  ClareiiduR  road.  Little  Woodhcuse,  Leeds.  FicC' 
Pro.  1677-9.     Trans.  4,     Hon.  Uc.  Sec. 

1880  BsAKroOT,  Abthub  Mudbk,  M.B.,  Superintendent  of  the 
Govern mcii I  Lying-in  Uonpiul,  Madran,  stiil  t'rufestor 
of  Midwifery  and  Diacaeea  of  Women  aud  Children  in 
tlie  MftdrftR  Medical  CO'lIfge,  Pantlioon  rofld,  Madras. 
Hon.  Loc,  See. 

1887  BxUQBR.  Ai>oLPHi;it  Bdwabd,M.D.  £(1.,  16,0rcbsrdBtrcct, 
Fortuian  iqaare,  W. 

IS72    BxmowATiiH,   Thomas,    M.B.,    Ilarrow-on-the-hill,   N.W. 

Omncil,  1684. 
1868*  Bbioos,  Hbnxt,  M.B.,  P.B.C.S.,  UtBodaey  at.,  Liverpool. 

TQL.    XXXU.  6 


FELLOWS   or   THE    SOCllTY. 


IB69 
1885 
1887 

1866 


IS89 


1 876 


1889 


18fi8 


1855 


EJeettd 

18&A     BUIOUT,  John  Mbabv^v,  M.D.,  Aliraeton,  Parle  hUl,  Forest 

hill,  S.E.     Council,  1873-74. 
BnisBAXE,  James,  M.D.,  16,  St.  John's  Wood  rond,  N.W. 
Briscok,  Jdhn  Freuebick,  The  LamninB,  Eaher,  Surrey, 
Brodie,  FaeD£E.icK  Garden,  M.6.,  Oak  street,  Fakenhnm, 

Norfolk. 
Bboixie,  GeobsbB.,  M. D., Consulting  Piiysician-Accouchear 

to  Queeu  Charlotte's  Lying-in  Hotpitali  3,  Chcstertield 

Btreet,  Mayfnir,  W.  Cownci/.  1873-75.   Pice-Prea.,  \SSS. 
Brook,  William  Hbkrv  B.,  M.B.Lood.,  P.R.C.S.,  County 

HospitB),  Lincoln. 
BuooEHoirse,  Ca^niEs  TuBiwa,  M.D.,  43,  Minor  roftd, 

Brockley,  S.E. 
Beown,  Alpubu,  M.A., M.B.,  CM.  Aber., ClaremoDt,  Higher 

BroughloD,  Mftiicliester. 
Broytn,  Andrew,  M.D.  St.  And.,    I,    Bartholomew  road, 

Keiitieh  town,  N.W.     Train.  1. 
BaowN,  D.   Dycb,   M,D.,    29,   Seymour   street,  Portraan 

square,  W. 
1889*  Brown,  William  CABNEorB,  M.D.  Aber.,  Penang,  China, 

1S76     BBUKJEa,  Martin,  33a,  Giouc^eter  place,  Portniati  squnre, 

W. 

Bbdnton,    /ohn,    M.D.,    M.A.,    Surgeon    to    the    Royal 

Maternity  Clinrity  ;  21,  Euatou  ro«d,  N.W.     Council, 

I871-;J.    Fice-Prct.  IS82'4.    Board  Exam.  Midwivet, 

1877-82.     TraM.  6. 

Buksh,  Uahkem,  Uvprpool  Housf, Balaam  ittrfet.FtaiiitAW,  E. 

1882*  BcLLEft,   AtiOLET  Cecil,    M.D.,    Ojifcrd   and  Cambridge 

Club,  Pall  Mall,  S.W. 
1885*  BCKNY,  J,  Bhice,  L.RC.P.  Ed.,  Newbury. 
1877     Bdechell,   Peter   Lodwick,   M.lt.,   Delnmcra,  Brndwcll- 
on-Sea,  Soutbminster,  S.O.,  Essex.     Cowncil,  1882-4. 
Vke.-Pret.  1885-7.     Board  Exam.  Mdwwe»,\^&^.T. 
Tran».  I. 
BiiHU,  EuwAftD,  M.J).,  M.C,  Senior  Physician  to  the  Salop 
Infirmary ;    Newport     Haute,    Shrewsbury.     Cauneil, 
1886./.     Hon.  Loe.  Set, 


1865 


1883 


1877 


FELLOWS    OF   TUK    SOCIETY. 


SIX 


Elected 

1888  BcnTON,  Hkbbeiit  C^mpbcll,  L.R.C.P. Loud.,  lee  Park 
Lodge,  niackhealh,  if.G. 

1878  IIcTLiiiuSurTHKfALiiitiirGHAULKSfM.lt.C.P.Ed., 76,  Brook 
street,  Grosvenor  square,  W.     Council,  1889-91. 

18(>8  Butt,  William  Fiibdekick,  L.R.C.P.  Loiid.,  48,  Pftrk 
aUvel,  OroBveiior  iquare,  W.      Conntil,  I87I5-78. 

1887*  BcxTON.  DoDter  W„  M.D.  Load.,  82,  Mocliioer  street, 
Can'udisli  «t|iisrp,  W, 

1886  Dtbrs,  Joun  W.,  M.D.,  Pbyfticiaa  for  Diseasca  of  Women 

to  the   Rojnl  Hoipital,  BclfMt)  Loner  crescent,  Bel- 
fast 

1883    Caldwell,  Williah  T.  D.,  M.D.,  209,  Brixton  road,  S.W. 

1887  Cahkhom,  Jambb  Cjialmeks,  M.D.,  PrafetBor  of  Midwifery 

and  DcKBscB  of  lofancy,  McGJll  University;  941,  Dor- 
chenter  street,  Montreal, 

1887     Caueron,     Mubdo'CH,    M.D.  Gins.,    7,    Newtou    lerrace, 

Charing  Croas,  GtaKgov. 
1888*  Campbell.  William  Maotie,  M.D.Edia.,  I,  Prinees  gate 

Bnst,  Liverpool. 
I8«I     Cakdlisii,  Hkxut,  M.D.,  6,  Barns  street,  Ayr,  N.B. 

1886  Cak?bntbk,  Akthcb  Bkiutowe,  .M.A.,  M.B.Ozou.,  Wykc- 

bam  HotiEC,  Bedford  park,  Croydon, 

1872  Carter,  CHAKr,t;s  I[bnrv,  M.D.,  Pliysiciari  to  tlie  Hospital 
for  Women,  Soho  Rquare ;  45,  Great  Cumberlaud  place, 
Hydft  park,  W.     Council,  1880-2.     Trant.  4. 

I890  Caktkr,  Robert  Jambs.  M.B.  Loud.,  Lock  Hospital,  Dean 
street,  Soho,  W.C. 

4877  Cakvkh,  Eustacr  John,  3,  Pulham  park  villaa,  Pulhiim, 
S.W. 

1887  Case,  Willuv,  3A,  WeatbouiDc  road,  Araadcl  e<iaare,  K, 
1869    Cabkib,  Johk   Boyd,  M.D.,    19,  Tyndale  place,    Isling. 

ton,  N. 

1863    Cayeek,  Thomas,  Maylield,  Aigbarth,  Ijiverpool. 

1875  Chakfubs,  KnwARD,  F.R.C.S.,  J4,  North  itreet,  Kcighley, 
Yorksbin. 


XX 


WLLUWS  Of    THE    SOCIKTY. 


1876*  CHAUFNiiys,  Francis  Hbnkt,  M.A.,  M.D.Otan.,  F.R.C.P., 

Pbysiciiiu-A'ccouclieur  to,  and  Lecturer  on  Midwifery 
zi.St.  Barltioloniew's  HriBpitHl,  GO,  Orent  Cumberland 
place,  W.  Council,  \fim-].  Hon.  Lil>.  i6^2-S.  i7«i. 
Sec.  I8S4-7.  Viw-Pr^t.  1888-1)0.  Hoard  Exam,  Mid- 
wtPM,  I8H3,  l**88.g0;   Cfiatrman,  1891.     Trana.  16. 

185,9  CBA^'C£,  Buw&KD  JOHK,  F.R.CS.,  Surgeon  to  the  Metro. 
poiitan  ¥ref  Hospital  tiTid  Citf  Orthopiedic  Tlonpilnl ; 
14,  TtiiHell  Kqimrs,  W.C. 

I8B6  Ceapm\m,  Charles  Willum,  M.D.,  Ti,  Fitijohira  avenue, 
H«rop»teB(i,  N.W. 

iSfiT*  Chaeles,  T.  Eumondstounb,  M.D.,  Cannea,  Fnmce. 
CoKKcii  1882-4. 


1874 


1886 


Cha-RLESWOBTH,  Jaues,  25,  Birch  terrace,  lUnley,  Stafford- 
ahire. 


1S68< 


1890 


1883 


CaASPSNnE&,  AhbhosgE.  L.,  M.D.  Durb.,  60,  Higli  ttreet, 
Urbridgf. 

CniLb,  Edwin,  "Vernlani,"  New   Maldcu,  Kiagston-on- 

Tliamei,  Surrey. 
CuiLDE,  Chabi,f.»  Pluulev,  B.A.,  L.R.C.P.  Loud..  Cnmcleii 

Ilouee,  KcDt  road,  Southaea. 

Childs,  CHKI8T0PHEK,  M.A.,  M.D.  Oion.,  2,  Royal  terrHce, 
Weytnoulh.     Hon.  Loc.  Sec. 

1863*  ClusnoLU,  Edwin,  M.D.,  Abergcldie,  Aaliiield,  near  Sydney, 
New  South  Wuiea.  [Per  Meaars,  Turner  and  licu- 
dtiBoo,  care  of  Measri.  W.  Davaon,  121,  CanuDD 
•Iret-i.  B.C.]. 

CnrrrMtOBK,  Thomas   Hiwieh,  L.R.C.P.  Lond,,  G&rdeu 
llouie,  Whcalbampatead,  Herts. 

CLArHAM,  Edwasd,  M.D.,  29,  Liiigfield  rund,  Wimbledon. 
ClaREMost,  Claudb  Glahkr,  Millbrciok   Houie,  I.  Hamp. 

Btcfld  road,  N.W. 
Clakks,  Reqinald.  South  Lodge,  Lee  parlc,  Lee,  S.E. 

C»~AV,  CHAttLEb,  M.D.,  Tower   Lodge,   Poulton-Ie-Pylde, 
ItBDCubira. 


TELLOWa   or   TBB   SOCIKTr. 


tx\ 


Sleeted 

1876  Clat,  Georoe  LANosroKD,  Weil  View,  443,  Moietey 
ruiu],  HigligHte,  BinniDgliBm. 

O.F.  CtAT,  John,  Profresor  of  Midwifery,  Qlieen'e  College,  Bir- 
minghum  ;  AUnn  U»u«p,  SteHhoiiup  )nne,  Birminghim, 
Couneil,  1868-69.     Vict-Preii.  1872-1. 

I8S9  Clemow.  ARTiiitR  nESRV  Wriss,  M,D.,  cm.  Edin.,  2, 
Talgarth  ronil.  West  Keiisingto]],  W. 

O.F.  Cleveukd,  William  Frederick,  M.D..  Slum  *iUn, 
I!)!),  MaidR  vnl^  W.  Cmnti!,  1863-64.  riee-Prti. 
1875-77,  l88;-[i9-     Trant.  \. 

1881  Closk.  James  Alex..  M.B..  P.O.  Boi  96,  Summerlield,  St. 

Clair  Ca.,  lUinoie,  U.S. 

1865*  CoATKS,  Charles,  M.D,,  PiiyeicifiH  to  the  Baih  General 
and  Roynl  United  HusjiitnU;   10,  Circux,  Bath. 

1882  CoATEa,  Phedbkick  William,  M.D.,  St.  John  street,  Salia- 

bury.     CbwnciV,  1691.     Hon.  Loc.  Stc. 

1878    Cockell,    Frederick    Euoab,    Jud.,    62,    Forest    road, 

Dalaton,  E. 
1875    CoPPiN,  KicHAKD  Ja8.  M&itlamd,  F.H.C.P.  Ed.,  98,  Earl's 

Court  roftd,  W. 
1878    CoFPiv,  Thomas  Walkrk,  22,  Upper  Park  road,  Harer. 

•lock  hill,  N.W. 

I87i»  Cols,  Richard  Brverlv,  M.D.  Jefferson  Coll.  Philnd., 
218,  Post  street,  San  Fmncisco,  California,  U.S. 

1888  Collinh,  Edward  TEm80^,  Canipden  House,  Oakficid 
road,  Sclly  park,  Kirmingkain, 

1884     Collins,  William  Job,  M.D.,  B.S,.  B.Sc.  Loud,,  F.R.C.S. 

Eiig.,  I,  Albert  trirnce,  Olouceater  gate,  N.W. 
1877     CoLMAN,  Walter  Tawkll,  The  Poplara,  Deddiogtoii,Oxi>ii. 

186fi     Coombs,  Jaubs,  M.D.,  Bedford. 

1874  CooPEB,  Hkbbert,  LR.C.P.  Bd.,  Tburlow  Hoiue,  Hamp. 
Btond,  N.W. 

L88B  CooPEH.  IVrsu,  L.U.C.P.  Load.,  StainlOD  Lodge,  filack- 
ixatb,  ^.U. 


xxii 


FSLL(]WS    OP    TOE    SOCIETY. 


18110  CoPtLAKU,  William  Hbnsy  Laukkncb,  M.B.CsnIitl).,  &g, 
Warwick  nimt,  Barri  Court,  S.W. 

1888    Corby,  Heniiy.  B.A.,  M.I)..  62,  Houlb  Mall,  Cork. 

1875*  COBDES,  ACG.,  M.D.,  M.R.C.P.,  Coosultiiii;  Accoucheur  to 
the  "  Mincriciirde;"  Frivat  Uoceiil  for  Midwifery  at  llie 
Uiiivorsitj  of  Geueva;  l2,RueBenol,Geneva.   Trans.l. 

\ii&3    CoBMiiu,  CuustiAM,  113,  Mile  Bnd  road,  E. 

li}S8  CoKNisii,  Charles  Newton,  L.K.C.F.  Bd.,  Bushey  Ilenth, 
H<>rtB, 

1S60*  CoHRT,  Thomas  Charles  Stbuart,  M.D.,  Senior  Surg«oii 
la  ihc  BelfHsi  General  Diapensarj  ;  OrmeBu  terrnce, 
Btlfaal.  Couf,dl.\m7.  Fict-Prirt.  18S\.  Hon.  Loc. 
See. 

1888     Cosy,  Isaac  Ri&iko,  L.R.C.P.Lond.,  Sliere,  GuiLdford. 

1875  Cory,  Bobkut,  M.D.,  AaBiatant  Obstetric  Pliysician  to  St. 
'riioniHs'fl  Hospital;  73,  Lambetli  Pnlace  road,  S.E. 
CoufffiV.  1879-8M884.5.  Fict- Prci.  \m7 -SB.  Tram.l. 

1886  Cox,  JoasvA  John,  M.D.  Ed.,  St,  Bonaii's,  Clareudoo  road. 
Eccles,  Manchester, 

1869  Cox,  HiOHAKi),  M.D.  St.  And.,  Theale,  near  Reading. 
TVaiM.  1. 

1877  Cbawfokd,  Jamkc*,  M.D.Durh.,  4,  Iddealeigh  MansioDB, 
Victoria  Btrtet,  S.W. 

1863  Chease,  Jame»  Kodbrtson,  F.B.C.S.  Ed,,  2,  Ogle  tcrraee. 
South  Shields. 

1881     Cbba&i,  James  Gidkon,  Rectory  lodge,  Briisted,  SeveiioakB. 

1863     C&SHtN,  Patrick  Johk,  M.I>„  4,  CfLmden  place,  Cork. 

1876  Cbew,  John,  Manor  House,  Highaoi  Fwrew,  Northim>pton- 

abire. 

Bd     Cbopt,  Hdwakd  OoTAViua,  L.II.C.P.  Loud.,  8,  Clarendon 
road,  Leeds. 

31     Cbonk,  Herbeut  Gbobge,  M.B.  Cantab., Kepton, near  Bor- 
tou-on-Ticnt. 


FBLLOWB   UV    TUX    BUCtBTY. 


XXUl 


BlKttd 

1886*  Cross,  Williak  Joseph.  H.H^  HorBham,  Victoiii,  Aut- 
tr&lis. 

1889     Clorc!!,  Edwabi>  Thomas, Lee  House,  Stoke  road,  Goeport. 

1875*  CuLLiKowoRTH.  CiUKLKs  Jamks.  M.D.,  F.R.C. P.,  Obstetric 
Fhyiiciau  to,  kikI  Lecliirer  on  OUtetric  Akdidne  at, 
St.  Thomas's  Uoapital  i  -)(>,  Brook  street,  Groarenor 
square.  W.  Council,  18»3-.^,  1891.  Fiet-trH.  1880-8. 
Uoard  Ezam.  Midwivet,  lS89.ai.      Trans.  7. 

1859  CusoEKVEN,  i.  Brbsbon,  Teddiugtoa  Hall,  Tcddington, 
S,W.     Council,  1870-72-     Trma.  3, 

1889*  CuBSETJi,  JciiiNoiK  J..  M.D.  Brux.,  94.  Cbundunwidi. 
Bombay. 

1885  Dakin,  W.  KADfOitD,  M.D,,  Obstetric  Fky*iciAD  to,  aiid 
Lecturer  on  Midwifery  at,  St,  George's  Ilotpiul ;  57, 
WelUcck  titreet,  CavendUb  s<jiiare,  W.  Cauneii,  I889- 
91.     Tram.  2. 

T888  Dalt,  Fkkukhick  HENBr,  M.D.,  ISS,  Amliurst  road, 
Hacknejr  Downs,  N.B.  Council,  1877-9.  Pict-Pret. 
I88S-S.    Tram.  2. 

1882    Dambrill-Datibs,  Wiluau  R.,  Alderley  l^dge,  Cbesfaire. 

1888    Daub,  Bobsiit,  Singnport,  Straits  Sclllcmfuta. 

1884  Darwik,  Geuuoe  Hlsby,  H.R.C.P.,  The  Cedars,  Albert 
park,  Diilsbury,  nenr  Maoclieeter. 

1689  Daties,  Frederick  Ukxbt,  M.B.,  CM.  Edia..  Tilbur;, 
Kssex. 

1876  Datibs,  Goher.  L.R.C.P.  Ed.,  9,  Pembridg«  villas,  Bays. 

water,  W. 

1884  Daties,  Jobx.  91,  New  North  road,  N. 

1885  Davjks,  Wiluam   MouBiaTOK,  H.D.,  55,  Gordon  square, 

W.C. 

1877  DaVbow,  Suith  Houston,  M.D.,CAmpden  villa,  -JOS,  Mnida 

laie,  W.     Couacil,  1889-91. 

[891  Dawson,  Ernest,  L.[t..C.F.Load.,  Th«  Mount,  Bajnit- 
stead,  >'.\V. 


XXIV 


rsuowa  or  the  aociBTV. 


itisg 


imd 


Bhcted 

1889    Dawson,  Whjjam  Edwabd.  L.K.Q.C.P.  ftL.M.,  83,  Cbi«. 
well  »treet,  B.C. 

1876     Day,   Hdmuns  Ovebma*!,  Assistant  Surgeon  lo  the  Ro^rI 

Infirmary  for  Cliildreii  and  'Wonieii,  Waterloo  Bridge 
road  i  78,  Wnterioo  road,  S,B. 

1880    Day,  William    Hamkes,  Surgeon  to   the  City  Primjn*, 
Norwich  ;  3,  Snrrey  sLri-tt,  NorwicL.     Trant.  I. 

Dav,  William  Henry,  M.D..  Physiciau  to  the  Samariwn 
Fre«  i!o«|iii«l  Tur  W'onitii  mid  Cbildreii  ;  10,  Man- 
clieBtcrequare.liV.   C»«mci7.  1H7,1-7S.   Ficir-i*rM.18M5-6. 

Dm  S'cEUX,   Harolu  a.,  M.D.  Brux.,  tl,  CnrlUle  Mnueiooa, 
Aeliley  placo,  Victorin  8tr*ct,  S. AV- 
IS-/    Dewah,  Joes,  L.R.C.P.  Ed.,  132,  Sloaiie  street,  S.  W. 
l8Bd     D'MoNTE,  DoMisicK  A.,  M.D.,  Bnndorn,  Bombfty. 

1887     DoDsoN,  Aktrdb  Edward,  Lll.C.P.  mid  L.il.  Ed..  Win- 
dcruivrc  villas,  Enrlafield,  Tooling,  S,W, 

1879    Dolan,  TuoitAs  Micir*Ei:,  M.D.,  Horton  houee,  Halifax. 

Donald,  Abohibald,  M.A.,  M.U.  Edin.,  274,  Oxford  road, 
Manchester,     Trans.  I. 

DoUAN',  Alban  H.  0.,  r.R.CS.,  Surgeon  to  tte  SamaritBQ 
Free  Uuii(>ilai )  9,  Granville  pince,  Portniau  square,  W. 
Ccuneil,  1B83-5.  Hon.  Lib.  lS81i-7.  Hon.Sec.  1888-91. 
Trans.  10. 

DoiiTY,  EuwABU  Henkk.  M.A.,  M.B.,  B.C.  Cnutalj.,  69, 
Bridj^e  street,  UiimUridge. 

DoTASToy,  MuwABD  Gl>MUNl>,  81,  QuecuU  crescent, 
Haverttoclc  hill,  N.W. 

DoWNES,  Denis  Sidney,  L.K.Q.C.P.  I.,  55,  KeutiBb  town 
ro«d.  N.W. 

DOTLE,  E.  A.  Qai^neci,  L.K.C.P.,  Coloniul  HuviiitnJ, 
Port  of  Spain,  Trinidad. 

Dbage,  CiiAttLEs,  M.D.,  Hatfield,  llerla.  Council  ISfiM. 
Tratu.  1. 


1886 


rxLLav/a  uf  tub  80C1sty. 


JLXV 


EiKied 

IWb  riuau.  Lo\£LU  M.A..  M.U.,  B.S.  (Oxon).  Burldgli  Mead, 
Hatfield. 

1871  Uiiakk-Bhockman,  Kuwahd  Forstbii,  F.R.C  S,  L.R.C.P. 
LoiiJ..  SurgGOii-Majar:  Siiperiiitt>n(!ent  V.ye  Infiriti«ry, 
Madras;  Profesior  of  Physiology  and  Opbllialmology,  ' 
Mndme  He^icnl  Cnllege,  [Ptr  Mpssre.  RicliarJdon 
Btid  Co.,  Enet  India  Array  Ageacy,  25,  fJaffolk  street, 
Pall  Mall,  S.W.j 

DaAKH,  CiiAiiLES  Heuey,  204,  Brixton  hill,  S.W. 

1S84     DoKE,  John  C,  The  Giett,  Lcviiham,  S.E. 

1883  DuKCAN,  Alexander  Geokoe,  M.B.,  25,  Ambunt  puk, 
StatnrordbiU,  N.B. 

O.F.  DrKOAN,  Jauss,  M.B.,  8,  Henrietta  nlreet,  Covent  gErdcn, 
W.C.     Comcii,  lli73'74. 

1888  DiKCAN,  Wtlliam,  L.1{,C,P.&  S.Ed.,  17,  RedUnd  grove, 
Bristol. 

1882  DCKOAy.WiLLiAU,  M.D.,  Obatetrio  PliiyBiclan  to,  aad  Lec- 
turer ou  Obstetric  Medicine  at,  the  Middleicx  HaapiliJ ; 
fi.  Hvley  Btreei,  W.  CokhciV,  ltj82-6,  lt)tJti-89.  Mon. 
Hi.  1890-91.     Trtms.2. 

1871  Kastes,  Gkdroe,  M.B.,  F.R.C.S.,  3&,  GlouceBter  place, 
Hyde  park,  W.     Council,  1S78-80. 

1883  EccLEs,     F.    KicuiRD,    M.D.,   ProfeftBor   uf    Physiology, 

Weuterii  Uuiv*n«iij  ;    I.  Ellwnodplwrc,  Quecu'snicuue. 
London,  Ontario,  Canada. 

Ehuiaxh,  Albkrt,  L.R.C.P.Lond..  Bttlerne,  near  Sooth- 
ainpton. 

187S  EtDKH,  Gmirck,  M.D.,  CM.,  Siirgton  lo  tite  Samaritan 
Ilocpiial  for  Women,  Noliingbaui  ;  17,  Regent  street, 
Nottingham, 

1878    Elleet,  Richard,  L.R.C.P.  Ed.,  Plymplon,  Devor. 

1873  EMOELidAXN,  Geobou  Julius,  A.M.,  M.D.,  3003,  Locuit 
Btreet,  St.  Louis,  Missouri,  U.S. 


^^^        ixvi 

PILLOWS    OF    THB    SOCIKTY.                       ^^^^^^^B 

1                 EiectfJ                                                                                                              1 
1               1884     Engljuh,  Thomas   Joenstoh,  M.D.,   128,   FuUmni  road,         J 

^^^^1875 

BwABT.  John    Hknrt,  Enstney,  Devon«liire  place*  Eut- 
botirne. 

I               I87fi 

FAttK0OHB8,  RicHAKD,  40,  B«lgrave  stree't,  GaUnll  litstb, 
Birmingbani. 

^"         1869 

Far(J,uhak,    William,    M.D,,    Deputy    Surgean-GeDerHl, 
Coouoor,  NeilgtiprrieB,  Mndras. 

1861 

Kabk,    Geo.    F.,    L.R.U.P.  EJ.,  Slade   Houae,    175.   Keu- 

■liDgloti  Totii,  8.R.      Cotin^l,  lS8o.                                    ^^^M 

18H2 

Pauka»,  JusEPii,  M.D.,  GaiciEborougb.                                   ^™ 

1868* 

FkoaS,  iliouAUU,  M.D.,  Wc»tcombc  park,  BlAckhentli,  8.K. 

188U 

Pbgbn,  CnAELGa   MiLro>,   DrvonBlurc   Houir,  Bnadgn, 

Suil'ollc. 

188(i 

Pennell,  Daviu,  L.K.Q.C.P.I.,  4,St.  Aniie'a  Villas,  Notling 
bill,  W. 

1883 

Fkntok,  Huau,  M.D.,  27,  George  airtct,  Uauovcr  square, 

W.                                                                                       H 

Fisher,  Fkgdebick  Bazlev,  L.B.C.P.  Lond.,  West  Walk,  ^^M 
Dorcbeater.                                                                               ^^^| 

!88() 

1882 

FiTKGKKALu.    Chables   Egertoh,    M.D.,    Went  Terrace,    ^^B 
Folkestoiie.    Hon.  Loc.  Sec.                                                   1 

1«77* 

FoNHARTiN,   Henky    u&,  M.D.,  1,  AncLor  Gate  terrace,          1 
Portsea.                                                                                             1 

^^         1884 

PoitD,  AlexaudbH}  L.R.C.P.Ed.,  9,  Beresfoid  street,  Water-          1 
ford.                                                                                         M 

^P 

FoBD,  Jameb,  M.D.,  Eltbam,  Kent.                                            ^^H 

^^          188-1 

FnuKACUE,  RuuKRi  Perbiman,  20,  Tdliugtou  pitrl:,  N.          ^^H 

1               1886 

FowLBU,  CiiABies  OvuEs,  M.D.,  Trevor  Ludjjr,  'Tliuruton    ^^M 
hcfttli,  S.W.                                                                        ^H 

1               18/5* 

Fkaslk,  Angus,  M.D.,  Pbynician  and  Lecturer  on  Oinical         1 
Medicine  lu  the  Abcrdeeu  Ku^aI  Jufirmaty  ;  232,  Uuioo          1 
Btrett,  Aberdeen.                                                                       1 

^^         1888 

Fbaber,   JaH£3    ALKXJ.NUEK,    L.R.C.P.  Load.,    Weetera          1 
Ludge,  Rumford.                                                             ^^^M 

FELLOWB    op   TDB   SOCIETY. 


xxni 


1860 
1883 

1874- 


Sf*ettif 

JS67     FiiBSHA!«,  HENBr  W.,  2'1.  Circus,  Bath.     Council,  1S91. 

Fby,  John  Blount,  Aehley  Lodge,  Esher,  Surrey. 

FuLiK«,  KENUt  RoxBLROH,  M  t).  CahuIi.,  44,  Curwo 
direct.  Maj-fnir,  W.     Trans.  I. 

KuaNEH,  WuLQUOBBY,  F.KX'.S.,  2,  BruDavick  jtlace, 
West  Brighton,     ffon.  Lot.  See. 

Galabin,  Ai.rKEU  Iikwis,  M.A,,  M.D,,  OhBtetric  Phjiician 
to,  and  Lecturer  on  Midwifery  at,  Guy'»  Hospital ;  49, 
Wimpolo  Blreci,  Cavendish  square,  W.  Council,  1876- 
78.  Hon.  Uh.  1879.  ffon.  Stc.  1880-3.  Viee-Prea. 
1884.     TVmi.  IPS.I-S.     Pm.  1889-90.     TraM.  12. 

Galloway,  Au'iuca  Wiltoh,  L.U.C.P.  Loud.,  7U>  New 
North  road,  N. 

Galton,  Joun  U.,  M.D.,  Cliuuani,  SylTan  road,  Up{>er 
Norwood,  S.E.     CuuacU,  ltf7-l-6,  1891. 

Oanuy,  William.  Uill  Toj),  Ceutral  liill,  Norwood,  S.E. 

Qaxub,  HijMLV  CuoKKB.,  P.K.C.S.  Bdin.,  Maryborougli, 
Queensland. 

Oakuinkb,  Brcvb  H.  J„  L.R,C.P.  Ed,,  Qlouceater  Uouae, 
Barry  roaci,  Eiwi  Dulwicli,  S.E. 

Garunkk,  Joflii'iViKAME.C,  llilltburo*  terrace.  Ilfracombe. 

Oabdkbb,  William,  M.A.,  M.D.,  I'rofeawr  of  Gyniccology, 
McGill  Uitiv«r(iity ;  GyiiEeCKLogiiit  to  tUe  Montreal 
General  Doapital;  109,  Union  ivenue,  Moulreal, 
Canada. 

GAENtK,  John,  I>2,  New  Hall  street,  Hirroingham. 

Gaktoh,  WiixiAU,  M,D.,  P.R.C.8.,  &&,  Bsgot  street, 
Wavertrer,  near  LtTcrpool. 

Geli,  Hsnrv  Willixohaii,  M.A.,  M.B.Oxon.,  43,  Albioa 
alTecl,  Hyde  park,  W. 
18M»  Geevjb,  Hbnby,  M.D.,  F.R.C.P.,  Consulting  Obatetrie 
PhyaiciaD  to  St.  Thomas'a  Hospital ;  •Id,  Harley  street, 
CsTendiah  square.  CounciV,  1864-66,  1»89-!»1.  lion. 
Stc.  1867-70.  FicvPret.  1871-3.  Trew.  1878-81. 
Pre*.  I8S3-4.     3V«m.  8. 


1863 

1681 
1886 

1S87 

1870 
1872 


1873 


I88g< 


XSVUL 


rELLUWS   OP   tHE    SOCIBTr. 


1666*  Gekvis,  Fbbueuiok  Heudkbourgk,  1,  Fellowa  rgaU, 
HaTerBlock  hUl,  N.W.    CmtncU.  1877-9.     Tram.  1. 

1884     GiBR,  CiiABLKit  John,  M.U.,  Wesigate  HouBe,  Ncwcutlir. 

\b7a  GiBUiKus,  AiiFKED  TiioMAB,  M.D.t  93,  RicbniDDd  ro&d, 
Dalston,  N.E.     CounoY,  t885.6,  1S88. 

1883  OlBBUKB,  RoBBHT  Al£Xander,  M.D.,  PliysicinTi  to  tlie 
Grottverior  Hoapital  Tor  Women  nnd  Children ;  29, 
Ciidognii  place,  S.W.     Co««c(A  1«89.9U.     TroM.  l. 

\9i7A     GlBsoK,  JjkMKS   EnwAKD,    Hilleidc,   Went  Cowes,    IbIb  of 

Wight. 
1869     GitL,  William,  UK.CP.  Loud.,  II,  Kuasell  tqiiare,  W-C. 

1671  GODnAKD,  UuoKNB,  M.D.  Durh.,  NortL  Lyoae,  Higtibury 
New  Park,  N.     Tram.  I. 

1871  Godson,  Cijcmest,  M.D.,  CM.;  9,  Grosvenor  street,  W. 
Cmncil.  187B-7".  Hon.  See.  1878-81.  VicePrct. 
1882-4.  Board  Exam.  Miiiwivea,  1877.  1882-86. 
Tram.  o. 

1H68  GoDniN,  Anuton,  M,D.,  28,  Brompton  cresoeut,  BtomptOD, 
S.W. 

1883     GoiLDoK,  John,  M.D.,  '20,  WickhamronJ,  Brockley,  S.E. 


E6S9 


1889 


Goss,  TueQKHNA  BiODULPU,  1,  The  Circus,  Bath. 
Lw:.  Sec. 


Bon. 


GocLLET,  CHAHLea  Artiiuh,  L.R.C.P.  Loud.,  2,  Fiuchlej^ 
road,  N.W. 

18S0     Gow,  William  John,  M.U.Loud.,49,  Weymouth  Btrwt.W. 
1689     GhaHam,  Authpb.  L.R.C.P.  &  S.  Ed. 
1B8£     Gkant.  Ooiltie,  M.D.,  Queeu  Mary's  Houbc,  laTemeaB. 
1890     Gray,  Haurv  St.  Claib,  M.l).  Glas,,  15,  Newton  terrace, 
GlaBgow. 

IS/S     Gh-at,  Jamks,  M.D.,  15,  Newtou  terrace,  Glasgow. 

1890     Gkbbn,    Charles    Datid,    M.D.Lond.,  Addiaon    House, 
Upper  Edmonton. 

1884     GaEBNK,  Waltbu,  L.B.C.P.  Lyud.,  Wallingford. 


PBLtOni   OP  THB   KOCtBTY. 


nh 


1887     Qbiimwood,  Edwik   Climsox,  L.R.C.P.,   19,  St.  John'i 
wood  park,  N.W. 

1663     OuiFPlTll,   U.    DK    Gobheqobk,  34,  3t.    Oeorge'a  equnre, 
S.W.     Trant.  2. 


1869 


1879* 


OuirFiTH,  John  T.,  M.D.,  Tnlfourd  floue,  Camberwell, 
S.R.     CounciU  l884-(;. 

GRimrii,  Waltick  Sfekckr  A>>nRR5io>i,  M.D.  CAHlnb., 
F.R.C.S.,  M.R.C.P.,  Aitiiiant  Pliyiician-. Accoucheur 
to  St.  Bartholomeir'n  JlospiW  ;  114.  Harley  street,  W. 
ConncU,  IA»fi.8.  Board  Exam.  Hi'itown,  1867-89. 
7V«w.  3. 


1870 


Gbioo,  William  Ceapmam,  M.D.,  Pliyiicmn  to  thn  In- 
|>atifiita.  Queen  Charlotte's  Lying-ia  Hoapiul;  ABsiRtniit 
Obatetric  Physician  to  the  Westminster  Hospital; 
27,  Cnwou  street,  Mnyfair.  CouneU^  187fl-77.  Board 
Exam.  Miilwinei,  I87H-79. 

886*  Gbiusdalk,  Thomas  Uabihotok,  B.A.,  M.B.  Cantab.,  SO, 
Rodney  atreet,  Liverpool. 

6BiHiiDALE,Tao3.  F.,  L.B.C.P.  Ed.,  Gvosulting  Sargeon  to 
the  living-in  llospitnl ;  29,  Rodiiev  AlrMi,  Liverpool. 
CvRMctT,  1861-62.      Fiet-Frtt.  1875-76. 

Ghippf-h.  Wai-TKR,  M.B,  Cantab.,  Tlie  Poptars,  Wallington, 
Surrey. 

Oeooono,  Walteb  ATKIS3,  Bcrwiclc  House,  Brondway, 
Stratford,  K. 

6B0TS,Wn.L[AHTllcl{MD,  M.D,,S|.  Ivea.  Iltintingdonsliire. 

QB0W9E,  WiLLUM,  L.K.C.F.  Lond.,  Miirloii,  near  Ra^by. 

Hackkbt,  John,  M.D.  Sl  And.,  Oaklande,  Hythe. 

Hadaway,  Jahkh,  L.R.O.P.  Bd.,  Dent.de.Ltoii  Villa,  Oar- 
iingc,  near  Margate. 

Haib,  Jahes,  M.D.,  Brinklow,  Corcntry. 

Halk,  Cuaklbs  D.  B.,  M.D.,  8,  Saaaei  gardene,  Hyde 
park,  W. 

U*Li«  Pbbdbbick,  1,  Jermyn  street,  St.  Jamca'a,  6.W. 


O.P. 


-I8S2 


1880 


1881 
1889 


18&9 


xxt 


FBLLOwa  or  ras  societt. 


1889     IUll,?krurbiok,  M.D.St.  Aud.,  St.  Mnrk's  Honsf,  Leeds. 

If>71  Halldwbs,  PRsnEBtcK  B.,  R««IbilU  B«igAte,  Surrey.  Cmtn. 
eii,  188.5-6.  I88ti-S0. 

IS$0  Hahes.  Georoe  ilENRr,  P.R.C.S.,  2,  Qacrnsborough  ler- 
r&cp,  W. 

1S87  Hamiltov,  ioas,  F.K.C.S.Cd.,  B<>?ctil)tir«t  Hoiuc,  Sviid. 
liucote,  Biirloii-(iu-Tieiit. 

1883  Hakrfihlu-Jonks,  SrosTAOC.  M.D.Lond.,  M.R.C.P.,  Joint. 
Lecturer  an  Midwifery  at,  nnJ  Phyticiaii-Accourlienr 
in  cliftrge  of  Oiit-patiunta  to,  Sc.  Mary's  Hospital ;  24, 
MonUpi  iqusre,  W.     Couneif,    HtitS'J.      Tratu.  \. 

18S0  Harwkv,  Ket,  Surgeon  to  the  We«t  City  DiBpentar;  ;  4, 
WHrdriibe  pince,  Docinra'  nommonR,  B.C. 

1889    IIaudwick,  Akthvh,  M.D.  Durh.,  Nevqiifty,  Cornwall. 

1S86  Hardy,  UBS»y  L.  P.,  Molly  Lodge,  Ricbmoud  road, 
Kingiiton-on<Tham«t. 

1889  flA'Rp'eB,  Charlks   JtiHN,  L.R.C.P.  Lond.,  Church  end, 

Fiiichley,  N. 

1977  Hahpeb,  Gerald  S.,  M.B.Abtr.,  40,  Cnrzon  street,  May- 
fair,  W. 

1878  Hahries,  Thomas  Datiks,  F.II.C.S,,  Gro»»enor  House, 
Aberyitwitli,  Cardiganaliire. 

1B67*  Habris,  William  H.,  M.O.,  7^,  Oxford  gjinJcns,  W. 

1861  IIakris,  William  John,  CLureli  Houae,  Heene,  Worthing. 
Hon.  Luc.  See. 

1B80*  HaWISOU,  IlicUABD  CitABLTOK,  lil,  SandringliBin  gardeiia, 
Baling.  W. 

1890  Haht.    Oavii)    Bbrbt,  M.D.Edin.,  29,  Chsrlotte  %(\u$.n 

Edinburgh. 

1886     Hartlkt,  Hokaob,  L.R.C.P.  Ed.,  Sloof,  SulTardalure. 
1888     llABTLBt.RBOiNALD,  L.R.C.P.  Ed.,  Kirlcgjitp  Home,  Think. 

1880  HAttVBif,  John  Stbphemsos,  1,  Aitvrood  road,  Cromwell 
road,  S.W. 


FELLOWS  OF  THE  90C1BTY. 


nil 


Elected 

1865  HAtTEX,  RoBBHT,  M.D.,  M,  Ohowringhee,  Calciiltii. 
[Per  Hesara.  Cuctiran  nnd  MncplierftOD,  153,  Union 
street,  Aberdeen.]    Tram.  I.     flon.  Lot.  See. 

1B86  HjLRTsr,  Sidkey  Fred.,  L.R.C.P.Loni).,  117a,  Qaeen's 
Gale,  S.W. 

1888     Haycock,  Hesry  Erw,^ki).  h,R.C.P.R(l.,  Whilwell.  Wdwyn. 

1873  Hatks,  Thomas  CBAWFOiin,  M.A,  M.l).,  F.U.C.P.,  Lee 
turer  on  Praoiical  Midwifery  at  Ring's  CoIlr(|;p; 
Obstetric  Fhyiiicina  to  Ki[ig*fl  College  Hoitpilnl  ; 
I7j  Clai^eo  dtrcet,  PJEcadillj,  W.  Gottwil,  [b7(i-78. 
FietPrtt.   1890-91. 

1880  Heath,  Wiu-jam  Lekton,  M.U,,  88a,  Cromwell  road, 
Qaceu'a  jjatc.  S.W.     Council,  1891.     Tranx.  1. 

1890  HsLMt,  T.  AsTiiUK,  M.D.  Bdin.,  St.  Mnry'i  Hospital, 
Mnnclitater. 

.  1867  HzMO&OQco,  John  Wiuum,  M.D.,  EArtdon,  Newcaatle- 
on-Tyne. 

1876*  Hkkuak,  Geokob  Ersb3T.  M.B.,  F.R.C.P..  Obstetric  Phy- 
eician  to,  and  Ijectiirer  on  Mitlwifrry  nt,  tlie  London 
Hospital  i  20,  Harlcy  atr««;t,  Cavendi^'li  equare,  W, 
Cfiunft/,  1878-79.  Hon.I.ih.:»SQ.\.  Hon.See.lSB'2-5. 
riee-PrtJ.  1SH6-;.  Board  Exam.  Mi,iarlrf».  18fiG-(*S. 
Trttu.  1889-91.     Traiu.  22. 

O.P.  Hbwiit.  Obailv,  M.D.,  K.R.C.P..  F.R.8.  Kd.,  ConiuUing 
Obetttric  Physiciau  to  Uuivcraity  College  Hvipital; 
ae,  Berkeley  itqimre,  W.  Hon.  Ssc.  18a9.64.  Trtat. 
iS6i.66.  Tice-PrM. 1 867-68.  yrM.lSfiSt-yft.  Tran8.21. 

IK60*  HioKS,  John  Hraxtoh,  M.D.,  F.R.C.P.,  F.R.S.,  Pliyiiciaa- 
Accoucbeur  to,  and  Lecltirer  on  Midwifery  and  Diirases 
of  Wamrn  m,  iit.  Mitry's  Hotpital  ;  34,  Georgie  atrtet, 
Mnnover  square.  Council,  1861.2,  18fi9.  Hon.  Sfe. 
1863-65.  yice.Pret.  1866.68.  Treat.  1870.  Pret. 
1871-2.      Tra>t«.  37. 

1860  Rioos,  TiiOHA!!  PRKDitRic,  M.D.,  BeMontfield  Houae, 
Dodley,  Worcestershire. 


nidi 


reLLom  nr  thk  tinriiTr, 


EImUH 

1836    H0A8,  Charles,  M.B.,  CM.  Aber.,  Bsotony  llotise,  Iliirat 
Grc«Ti,  riawkhuntl  (ilRilwiiy  Sintion  RoiicrtRbridge). 

1886     HonaF.s.    Hbrbrkt  C[Iamket,    L.R.C.P.  Land.,  Wattan. 
Hcrta.     Traiu.  I. 

0.f.      H0DQR3,  RiCHAKD,  M.D.,  F.R.C.S.,  3l5.  Harewood  squnrr. 
N.W.     TVffiM.  3. 

IB87     HoDSON,  HENiir    Alokukon,    L.K.C.P.  Erf.  Ik  L.M.,  23, 
BniiiRirick  iquare,  Brighton. 

tSSfi    HoLUKBTO!!,     HBVU-t     NsLBoV,    L.R.C.F.    tond.,     BmI 
MoUscy. 

I87S     HoUriNns,  Ii)DWtii,  M.D.,  25,  Endakigh  gardens,  N.W. 

Council,  ISH8.gU. 
1880     IToLLOW-M,  William    Oborob,  B.A.,  M.D.  Canlab.,  Gut 

Sussex  Jlukpitni,  iluBtiiigs. 

1859  HOLMAN,  COVSTANTINE,  M.D.,  The  Barons,  Reigste.  Surrey. 
Council.  1867-69.     Vice-Pres.  1870-71. 

1880  HowiBALL,  OacAB  DUNscOMBB,  M.D.,  George  Town.Dcmc- 
taru,  Britiflh  GuiHiia. 

1864*  IIooD,  Wdakton  Pbtkr,  M.D.,  11,  Seynioiir  itreet.  PorU 
man  aqunre,  \V. 

1872  HOPB,  Wlti,rA«,  M.D,,  Physician  to  Queen  CbBriolle's 
Iiyiiig-in  Hoipital  ;  56,  Ciinian  street,  Mayfair,  W. 
Council,  1877-9.     Board  Eram.  Mdviites,  1873-4. 

IS8I     HopKiNB.  John,  L.R.C.P.  Ed.,  Sa,  Cam  Let  we  11  ntad,  S.G. 

1883*  HoKiiooKS,  Pet£r,  M.D.,  F.R.C.P.  Loud.,  Asfeietant  Ob- 
alftrio  Physician  to,  and  Deinoii»trAtcir  of  Practical 
OHttclric*  «t,  Guy's  HoBjiitid  ;  'id,  Si,  Thomng's  street, 
S.E.  Council,  1886-7.  Urn.  Lib.  1888-9.  Hon.  Set. 
lKa0.9l.     Tram.  I. 

1876  RoftsHAK.  GoDFHBY  Chaslks,  22,  King  street,  Portman 
square,  W, 

(883     H&sKiN.  TnBoPHii.ua,  L.R.C.P.  Lend,,  l86,Amhur«t  road, 

N.K, 
1B83     Hoconiw,  Edmund  Kiso,  L.R.C.P.  Bd.,  23,  High  street, 

Si('[>ney,  B. 


FRLLOWB    OF   THE    SOCIBTr. 


XXXll) 


1884  HouoH,  Cai.RLKs  Hekrt,  Full  street,  Derby. 

1877  Howell,  Hobacb  Sydney,  M.D,,  E«st  Grove  Houae,  18, 

Boundary  road,  St.  Joho'a  Wood,  N.W. 
1879     HuBBAftD,  Thomas  Wblls,  Rock   Hoiite,  Boiightaa  Moti- 
clieUen,  Maid  stone. 

1885  HCGHES,    Bdgar  a.,   L.R.C.P.Loiid.,  10,  Old   Cavendich 

■ireet,  W. 

1689  HuuFHBTS,  Chablbs  Beyes,  L.H.C.P.  &  S.  BcUn.,  Tfa« 
Pnplara,  Haramooden,  Keat. 

l*^*  EfCBBT.  Jamie»on  Botd,  M.D.  Centab.,  43,  Castle  strtet, 
Reading.     Councit,  188:~.!>.     Tranj.  2. 

1878  HcBBAyo,  Walteh  Edward,  56,  Duty  New  toad,  Man- 

cbeiler. 

1882  HcTTON,  Robert  Jamis,  L.R,C.P.Ed.,  Carsbalton  StapLe- 

ton  Hall  road,  Finshnry  park,  N. 

1883  IsMAX,  RoiicKT  EuwAHn,  Gadshill  Cottage.  Highani,  Kent. 

1884  Irwin,  Johv  Arthcr,  M.A.,  M.D.,  14,  West  Twenty-ninth 

alrect,  New  York. 

1887  Jacesom,  G.  E.  Corrte,  F.B.C,S.  Ed.,  5,  Gt.  Marlborough 
atreet,  W. 

1883     Jacksok,  Georoe  Hekbt,  €,  Cliff  Bridge  terrace,  Scar- 

boroagh. 
ISN)    Jackson,  James,  15.  F{ui:itin)*cton  street,  Bamabnry,  N. 
1873    Jakiks.  William  Vobper,  L.R.C.P.  Ed.,  IS5,  Collins  Btreel 

East,  Melbourne. 
'IB72     Jallasd,  RunBHT.  Uorncaitle,  Lincolnihire.     Tran*.  I. 

1890  Jamr9,  Ciiable!^  Rbsbv,  L.R.C.P.Lnnd.,  Snrg.  Indian 
Army  (care  of  MesBfa.  Qrindlay  and  Co.,  55,  Parlia- 
ment street,  S.W.). 

977     Jaiiiesox,  Patrick,  M.A.,  3,  St.  Petw'a  atreet,  PeterJiead, 

Aberdecnehire. 
B85     Jahibson,  Bobbrt  Alexavdkr,  M.D.,  ShaDghni.     [Per 

Meaars.  Henry  S.  King  and  Co.,  05,  Cornhill,  E.G.] 

386    Jamison-,  Arthur   AHDiiE^r.  M.D.  Gla»..    18,  Lowndea 
•Ireet,  S.W. 

TOi»  zzxu.  e 


xzxiv 

FELLOWS   OF   THE                                            ^^^^^^^^| 

ZItcteJ                                                                                    ^^^^H 

I883» 

JENKIK9,    Edward    Johnbtone,    M.B,  Oion.,    AiiftrnHnn         ■ 

Club.  8yd[if)'.     [P«r  H.  K.  Lewifi,  13C,  Gover  ■trcel,         H 

W.  C]                                                                                   ■ 

1877 

Jfnk3,  Edwxhd  W.,  M.D.,  84,  tsfayetle  «cinio,  Detroit,   ^^H 

MictiigitD,  U.S.                                                                ^^M 

1682 

Jbnninos,  CHAnLEi  Eoehtow,  F.R.C.S.  Fng,,    Asiistanl    ^^H 

SiirKCon   to   the   Norih-West   London    Hospiial  ;     l.i,    ^^H 

Upper  Broalc  street,  Orosvenor  square,  W.                        ^^^| 

1689 

Johns,  HtKar  Docqlas,  L.R.C.P.,  The  DiBpctiBary,  GntM-        V 

M 

ISSi 

Johnson,  Arthdb  Jdkes,  M.B.,  52,  Bloor  itreet  We«t,  ^^H 

Toronto,  Oatario,  Cennfla.                                               ^^^| 

I88B 

JoHJJSON,  John  Geokoe,  L.R.C.P.  Loud.,  Concrete  Hoase,  ^^H 

^^H 

Swindon.                                                                                        ^M 

^H        1877 

Johnson,  Samuel,  M.D.,  5,  Hill  street,  Stokc-upon-Trent.           H 

^H        1881 

Johnston,  Jobeph,  M.D.,  24,  Si.  Jolm'i  Wood  park,  W-W.          H 

^^B 

Couneit.  1891.                                                                        1 

^H         1879 

Johnston,  Wm.  Bbecii,  M.D.,   157,  Jatnaics  road,  Ber*         ^ 

^H 

mondsey,  S.E. 

^H         1868 

Jonks,  BTAN,Ty-Mawr,  Aberdare,G]BitiorgBiislMre.    Couneil, 

^^B 

188fi-8.     Vice.^Pret.  1890-91.     Hon.  loc.  See. 

^H 

Jones,  II.  Macnauobt&n.    M.D.,   F.R.C.S.I.  and  Edio., 

^H 

141,  Hnrley  mrcet,  Caveiidial]  kijuare,  \V. 

^H          18HI 

Jonbs,  James  Robert,  M.B..  171,  Donald  atreel,  Winnipeg, 

^^1 

Manitoba,  CaTiada. 

^H 

JoSEs,  John,  60,  King  atreet,  Regent  siroet,  W. 

^^^^  1887 

JoNEB.  J.  TALrouRD,  M.B.  Land.,  Rone  Bouli,  SuutU  terrnct, 

^^^^H 

Eastbourne. 

^^^^1886 

JoNsa,  Lewis,  M.D.,  Onknmd,  Balbam,  S.W. 

^H         1885 

Jones,  1*.  Svdnet,  M.D.,  16,  College  street,  llyde  park, 

^^H 

Sydney.     [  i'er  Meaarit.  1),  Joiien  and  Co.,  1,  Greaham 

^H 

buililirgt,  Baaiagliall  street,  B.C.] 

^H 

JosHS,  PuiUP  W.,  Silver  elreet,  Enfield. 

^^^^I8U6 

Jokes,  William  Owen,  Tlic  Dowm,  Bowdon,  Maiicbcatcr. 

* 

FBLL0W8   or    THK    80CIBTT. 


XXXV 


1879  JotTBEBr,  Charlss  Henry,  M.B.Lont!.,  K.R.C.S.  Eng., 
Snrgeou-Major,  Dengiil  MedJcul  Dfpt.,54,  CbowringUee, 
CalcuttB. 

IBTB  JCDSOK,  TnoMAS  Rodbrt,  L.R.C.?.  Lond.,  Hayman'a 
Grecii,  West  Derby,  LiTcrpooL 

1875  JOKBi,  AucrsTus,  M.B.,  N.  W.  Monwled  Police,  Regina, 

N.-W.  Territory,  Canndn. 

1876  Kanb,  Na.tiiakiei.  H.  K.,  M.D.,  l.anherne,  Kingiiton  hilf, 

Surrey. 

1890  KASTHAcit,  Alfrkiio  Axtunks,  P.HX.S.,  St.  Bartholo- 
mtw'a  Huspital,  E.G. 

1884  Kkaies,  WiLLiAU  CooPBK,  L.R.C.P.,  2,  Tredegar  villas, 
Eflitt  Diilwich  rond,  S.R. 

1S80    Kbbbbii.,  ALruKL),  Flaxton,  York. 

O.F.  Kkklb,  Geoiiob  Tiiouas,  fli.  St.  PanPa  road.  High, 
bary,  N.     Council,  1385. 

1883  Kkelimo,  Jaukh  IIukd,  M.D.,  2(i7,aio*sop  road,  Shtffit^td. 
ffoM.  Loc.  Sec. 

18S0  KliiTU,  Skesr.  M.B.,  C.M.Edin.,  -12,  Clitrlea  tincl, 
Berkeley  Square,  W. 

1674  Kkmi'steu,  William  HE»HY,M,D.,Oak  House,  Bridge  rood, 
BaUersea,  S.W. 

1886  KcKNKDr,  ALraicn  Eeimukd,  L.R.C.P.  13d.,  ChesLtrloii 
Houu,  PUiBtow,  K 

1879  Keh,  Hooit  RioiiARi),  L.B.C.P.  Ed.,  1-1,  Devouahire  Boad, 
Balltani,  S.W. 

1873    KSKB,  NoRUAN  S.,  M.D.,  P.L.8.,  42,  Orove  road,  R«genl's 

park,  N.W. 
1877*  Kbeshill,  Johk  Bbdpord,  M.R.C.P.   Ed.,  Fairfield,   St. 

German's,  ComwalL 
1878     KaoBY,  RrsTOXJBE  NA8Biiw,i>iiF.K,  M.D.  Bruswls,  L.Med. 

Bombay,  PliyBician  to  tbc  P«r«ll  Diipenury,  Bombay  ( 

Girgaum  road,  Uombny. 

O.y.  KiALLMAiK,  Hesry  Waltew,  3,  Pfmbridge  gardens,  Bayn- 
•ater.     Counnl,  l»;g-80. 


XXXVl 


PrLLOWS    OP    THZ    SOCIETr. 


Ktnttd 

IttSO    EiNGSPORU,  Edward,   F.R.C.S.,  Surgeon  lo  tlie  Suiiliury 
DispeniKty  ;  Siinbiiry-on-TUaiueB. 

1872*  KiscB,  Albert.  3,  Sutherland  gardens,  Mnidn  »nle,  "W. 

1876     KsoTT,    CiiAaLKB,    M.K.C.F.  Ed.,   Lii   ViUe,   Elm    gror*, 

Southiea. 
Lakr,   Geohoi   Robert,   79,  GlouceaWr  creacent,   Hyde 

park,  W. 
LJtKSFOBD,  CUAHIES  P.,  Suiiiiyside,  HornKcr  Inne,  N. 
Lakohohnf,  Thomas  Giunt,  Minioent,  S.  Australia. 
Laholey,  Aaron,  L.RC.P.  EJ.,  M9,  WnUortli  road,  S.E. 
LANXH:3TeK,  TIekiikht  Hexrt,  M.B.  Lond.,   1,  Elm  park 

gardcDB,  Soutti  Kenflington,  S.W. 
Laudek,  William.  M.D.  Edin.,  260,  Oiforcl  road,  Man* 

chrnter. 
Law.  William  Thomas,  M.D.  Edin..  9.  Norfolk  creecent,  W. 
Lawrence,    Alfred    EnwARi)   Atisx,    M.P.,    Pbysicinn- 

Accoiicheur     to    the    Bristol    General    KoBpital ;     19, 

Eichmond   liill,   Ciiflun,   Briatol.      Council.   1BS5.86, 

1&S9.     Vkc-Prei.,  \%m-9Q.    Hon.  Loc.  Stc.    Trans.  I. 
Leachman,  Albert  Warbek,  M.D.,  Fairley,  Peterafield, 

IlanU. 
I86<1*  Lediabd,  Henrv    Ambboee,   M.B.,   43,  Lowther  «treet, 

Carlialc.     ChuncH,  ISflO-'JI.     Trans.  1. 

Lees,  Epwin   Lkonabjj,  M.D.,  CM.  Ed.,  2,  The  ATenue, 

RedLand  rond.  Briatol. 
Leisuman,   William,  M.D.,  Physician   to  the  Univeraity 

Lying-in    Hoopital,   Kegius  Proft'saor  of  Midwifery  in 

the  UniTersity  of  Glaagow  ;    11,    Woodnde  crenunt, 

GlMgow.      Comeil,    1866-68.      Viee-Prn.    1869-70. 

Trana.  I. 
Lkwerr,  Akthuh.  H.  N.,  M.D.  Lond.,  M.R.C.P.,  Aemlant 

Ohfttetric    Pliyiioian    to    the    Londun     Hospital ;     60. 

Winipolc  street,  W.     Council,  I8s".8fl.     Trtina.  C, 

Lewis,  Bhnest  E.,  L.H.C.P.  Lond.,  Middleaez  HoRpitnl  ,W. 

Lewis,  Joun  RlOOd  Milled,  M.D.,  Deputy-Surgeon  General 
Markbam  J^odgi',  Liverpiiot  rund,  Kiiig«t«ii  hill,  Surrey 


1889 

1867* 

1887 
1883 
1886 

1886 

1887 
1875 


1878 


1887 


I860 


1885 


1890 
1877 


rELLOWS    UF   TUK    SUCIKTV. 


XXSTII 


1885  LisiiBD,   SvDNSr    Robbkt,   L.It.C.P.  Ed,,   48,   Charlott« 

street,  Hall. 

1875  Ljxbmak,  Carlo,  M.D.  Vietina,  Prinoipul  Surgeon,  Trievte 
Civil  Ho«pital,  TrieBic,  Austriii.     Trans.  1. 

1874  LltHQOW,  RoBBBT  Alexa-Nues  Oouqlab,  M.D.,  27a, 
LowudoK  street,  Belgrave  Hqiiare,  S.W. 

1868  Llewellyn,  Evan-,  L.R.C.P.  Ed.,  Th«  Utnea,  Baw  road, 
E. 

1872*  Lock,  John  GRiPPiTn^  ALA.,  2,  Rock  terrjiee,  Teabj. 

1659    LouuK.  TuoMAS  ROKBKT.  M.D.,  Bemerton,  Torquay. 

1890  Low,  Habiilu.  M.B.CmilAb.,  Round  Hill  Villa,  Syden- 
ham, S.E. 

1862  LoTiB,  Gbobsk,  F.U.C.S.,  5,  Uorainglow  street,  finrtoii-oa- 
Trent,  StAffordsbirc.  Couneit,  1867-89.  Tram.  2. 
Hon.  hoc.  See. 

1890  Lubbock,  Eduab  AsHLbY,  L.R.C.P.Loa(l,,  -I,  WeatQelil 
terrace,  Fulhuni  road,  S.W. 

1873  LxJSH.  William  John  Hknrt,  M.D.Brux.,  FyHeld  House, 
Andofer. 

1878*  Ltcett,  Johx  Allan,  M.D.,Tbe  "  Hftllies,"  Graiselcy,  Wol- 
verhamptOQ. 

1871  McCalldm,  Duncan  Campbell,  K[,D.,  Eni«ritua  Professor, 
McGill  Unmnitf ;  Aa,  Uuioo  avenue,  Montreal,  Canada. 
Tram.  4. 

1890  McCamk,  Febdebick  John,  M.B.,  C.M.Edin  .The  Hoipital 
for  Sick  Children,  Grent  Ormond  otreet,  W.C. 

IS90  McCait,  John  Dtsart,  F.R.C.S.,  Ivy  House,  Linfolu  road. 
East  Finchley,  IS. 

1879    Mackbouoh,  Oeorrf.  J.,  M.T>.,  Chailiam,  Ontario,  Canadn. 

O.F.  Mackikdeu,  Obapkk,  M.D.,  Connulting  Surg«on  to  the 
GainHborougli  Pi#prusary;  Gaiiisboroiigb,  Llncolnilitre. 
Otmndl,  187 1-3.     TVsim.  2. 

1886  HcMnLLKM,  Willun,  L.K.Q.C.F.I.,  3t9A,  Brixton  road. 

S.W. 


xxinn 


FELLOWfl    HI'    THE    80CIKTV. 


£leeted 

1839     Ukvox.,  llESicr  M.,  M.I>.,  A,  Upper  Wimpolc  utrctt,  W. 

Cotneil.  i8C3-65,  1884.     Vict-Pret.  1872-4.     Trsju. 

15. 
1864     Malcolm,  John  D.,  M.B.,  CM.,  2-1,  Brynnslon  Btrpct,  W. 

1871     Malins,    KuwAiii>,    M.O.,    Obstetric     I'lijaiuian    to    tlie 

Geiieml  Uoipitd,  Uirniiiigbfim  ;    8,  Old  xiuan,  Bir- 

Tninghnm.    Council,  1881-3.     Fi>*.PrM,  188J-6.    Hon. 

Loe.  S«e. 
I86K*  Maiicii,    Hknbv    Coli-bv,    .M.U.,     2,     WeJt   street,    Kocli- 

iIhIp.      Couneii,  18^0.91. 
1887     Mahx,  LBONA.BO  P,  L.K.C.P.  Loiidi.,  19,  Upper  Berkeleji 

ilreet,  Portman  «qiiare.  W. 
I860    MABi-nr,  Uknky  Fhkubrjck,  t'lie  Nook,  PaJsitow,  Coruwull. 
1862     MAaKioTT,  &0BEiir  BiroUAKAK,  Swsffbam,  Norfolk. 
1887    Maksii,    0.    E,    Bulwek,  UR.C.P.  Ed.,  Vcntiior  House, 

Newpori,  Mouniotiiliisliire. 
189U    Maktik,  CiiinsTOPiiEH,  M.B.,  C.M.Edin.,  '6,  The  Crescent. 

BirmiDgtiam. 
1873    MAaTiN,  Hbnrv  Chjuuhnoton,  M.B..  CM.,  II,  Bomepi 

pUce,  Uyilc  park,  W.  * 

1887     Mabon,  AiiTHUK  Hekuy,  L.R.C.P.ljond.,  OakwoocI,  Walton- 

oii-TIiAiiiee. 
1884     Massey,  IIuqu  Hollaku,   2,  North  terrace,  CambcrwcU, 

S.E. 

1B84     Ma8Tbb8,  Joiim  Ai.riiBi),  L.R.C.P.  Lond.,  Weatfill  Hfluse, 
litaok  green,  W. 

1877     MaVMSkll,  li.  WiuuHHAM,  A.M.,  M.D.,  Pitl  anJ  Londun 
titrtet,  Dunedin,  NewZcalaml. 

1883     MAKnicE,  Oliver   Oallki,  76,  London  atreet,   Kcadlng. 

Council,  I88S-9U. 
189il     Mat,  Chichester  Goulu,  M.A.,  M.B.  Cnnlob.,  13,  FiU. 

villijini  Bqimre,  Dublin, 

1677     May,  Lnvvia  Jasiks,  liountis  T borne,  Sereu  SUlera  road,, 
Fiuabury  park,  N. 

ie»A     Mavnabu,  Kdwaku  Charles.  L.B.C.P.  Ed.,  11.  Shellons 
■iruet,  Folkeaioue. 


nU.OW»  OF   THE   lOCIBTY. 


XXUI 


1886 
]»83 


18?5< 


EletteA 

1885     Mbllsb,  CHaoLBS  Bootu,  L.R.C.P.  Ed.,  Cowbridgr,  Gin. 
morgftnsliire. 

Mensem,,  Zebulon.  31,  Shepherd's  Biitli  rond,  W. 

Mekkdith,  William  Ai-pleton,  M.B.,  CM.,  Surgeon  to 
the  Samnhlnn  Free  UoHpitsI  for  Womrn  nnd  Children  ; 
fl,  Qiie«n  Anne  utrect,  Cavendiili  n^iinrp,  W.  Council, 
1886-8.     Fite.J'rea.  1891.     7VoM.  2. 

Miles.  Abijah  J.,  M.D.,  ProfcMOr  of  UiitcnseB  uf  Womeii 
sad  Ckitdreii  tu  tlie  CinciuuaLi  College  of  Medicine, 
Cincinnati,  Ohio,  U.S. 

1676  HiLLH.vN,  TubMAS,  M.D.,  M<1r  Spadina  nventie,  Torontii, 

Ontario,  Ckiih^d. 

1880     Mills,   Robeht  James,  M.B.,  M.C.,   AJl  SainU'  green, 
Norwich. 

1876     MiLsoM,  KEcirARt)  EIenrt,  M.I>.,  88,  Finchlcy  road,  Soutli 
llRmpiIead,  N.W.     Council,  1890. 

I869»  MiKNB,  Pembroke  R.  J,  B.,  M.».,  Thctford,  Norfolk. 

1867     MiTcniiL,  RriHERt  Nathal,  M.D.,  Chesier  Uouse,  Wiclc« 
liani  road,  Brocklcy,  S.E. 

18«8    MooTiioosAWMY,    P.  S.,   M.D.,   F.L.S.,  Tanjore,  Madras 
Presidency.     Tratia.  1. 

1677  Moon,  PiiKDeiticK,  M.B.,  Bcilcy  house,  Greenwich. 

1873     Moon,    KurnsUT    Hgkrv,    F.B.C.8.,    I6U,    Norwood    road, 
West  Norwood,  S.K. 

1859     MoORaEAD,JoUN,  M.D.,  Surgeon  to  Ibc  Weymoutb  Infir. 
mary  nnd  Uiapensiiry  ;  Weymoulli,  Uorset. 

IdgS    MoitoAS,  QeoHfiK  Johv,  L.K.Q.C.P.  &  L.M.,  DovaBtau 
Uouae,  Kinnerley,  near  Oswestry. 

1888    MoHiBOK,  Alkxakuum,  M.D.Ed.,  DunnoiUr,  1 1.1,  Green 
lanes,  Stoke  Ncwinglun,  N. 

1890    MooBis.  CiuRi.es   Arthdr,    M.A„  M.B,,  B.C.Cantab., 
F.R.C.S.,  3(1,  Kbnry  street,  S.W. 

186.1     Mouuis,  Clarke  Kslly,  Gordon  Lodge.  Charlton  rond. 
Black  Ilea  ih,  S.a 


rBLLovrs  or  tub  suuibtv. 


1878 
1885 

1887 
O.F. 

1888 

1887 


Elected 

1891  MuKTLOCK,  CuAULKS,  L.R.C.P.Loud.,  9,  Ladbrvke  gordeuo, 
W. 

1886  MoKTON,  SujkUFURTH,  M.D.  Durham,  Wdlcsley  tUIas. 
Croydou. 

1879  MouLLiN,  Jahks  A.  Maksrll,  M.A.,  M.B.,  AniaUnt 
I'byHician  to  the  Hospital  Tor  WomcD  mi<l  CLildrcn, 
69,  Wiiiipole  street,  CnTcndieli  Kquartr,  W.     Trana.  1. 

MoWAT,  GKOHOE.49,Bt.  Peter  street,  St.  Albana.  Tram.  I. 
Murray,   Chaklbs    Stokhont,    L.R.C.S.  nnd  L.M.  Kd., 

8i,  Gloucp«ler  place,  Portman  square,  W. 
McKBAY,  Horace  H.  C,  470,  Hornsey  road,  N. 
ftltisGRAVR,  JoiiKsoK  TuOMAA.  L.S.C.P.  Ell,  IrUm  Villa, 

39,  Finchleyroail,  N.W.     Council,  1H59-6U.     Tront.  I. 
Mtbuelton-Gavey,  Edwabu   Ubbukkt,  64,  St.  Matthew's 

»tre«t,  Ipvwiob. 

Napikr,  a.  D.  IjEITH,  M.I).  Aber.,  67,  GroBTcnot  Mreet,  W. 
Trant.  I. 

1859    Nbal,  Jaues,  M.V.,  Parterre,  Sandown,  Ulc  of  Wight. 

1882  MEailAU,  Tiiuuas  CAitucti.,  M.D.,  Lecturer  on  Midwifery 
iu  tbe  Univer»ily  of  i>urliam  College  of  Mcdiciu«  at 
Kewcaatle-cn-Tyne ;  12,  £Uiaoa  place,  NtwcaBtle-on- 
Tyne.     Council,  L889-9I. 

1859*  NtWNAV,  William,  M.D.,  Surgeon  to  the  Stamford  and 
Riitluiid  liilirniKry :  Bnni  Hill  Iloufie,  Stamford, 
tincnliiahire.  Council,  1873-75.  VUit-Pret.  1676-77. 
Traitt,  5. 

Newsham,  William  FlAttnY  Chbistopueh,  M.A., 
M.B.Cniitalli,,  1,  Leiceiter  place,  Cliftuu,  Briatul. 

Nicholson,  Arthur,  M.B.  Lund.,  98,  MoDtpellier  road, 
BnghtoQ. 

1879  NlOHOLaoN,  Emilius  Rowley,  JM.D.,  11,  Telford  atttiue, 
Streatham  bill,  3.W. 

1876  Nix,  Edward  J.vues,  M.D.,  WA,  Great  Portland  street,  W. 
Ccuneil.  ISSy-SK). 

1882     NoiiUA»,  JouN  HOWARD,  Liamorc  Uouac,  Uobbiirn-ou.Tync. 


1889 


1873 


tfEU.on8   or  THE    SOCIETY. 


xli 


1883  HvKS,  Phiup  W.  G.,  L.R.C.P.  Lond.,  MapleBlead,  Clirisl. 

church  road.  Botimeinomh. 

1884  Oaxbs,  Autuuk,  M,D.,   liachamendp,  StUTcloy  roml,  Eaat- 

kiurne. 
1880    Oaklri,  Johk,  Holly  Hoiiae,  Wood's  end,  Halifm,  York- 
■hire. 

18S6  OOLE,  A&TtiDtt  Wb3Lby,  L.K.C.P.  Lend.,  90,  CAitnon 
H«ct,  E.C. 

1876  003TO,v.  Francis,  M.D,,  Lecturer  on  Hygiene  mnd  Medical 
Jiiri»[)rui)eiice  in  the  University  oT  Otngo ;  Dunedio, 
New  Zcfllaad  (per  iiichard  W.  K.  liuin,  14(),  Union 
iireet,  Aberdeen). 

O.F.  OuJllAM,  Hkkuv.  M.D.,  F.R.C.P.,  Oonaalling  Ohatetric 
PbyaiciAu  to  Guy's  llospiul ;  -I,  Oavcu<ii"h  |>lncc,(*ikven- 
aiiti  nqimtc,  W.  P'iee-Pr«t.  I8fi!J.  Vaunetl,  1850, 
1865-66.  Trtaa.  186K62.  Pre*.  lSe3-64.  Trant.  I. 
Tnutn. 

1888  OLITB&,  Frakklis  Hbwitt,  L.R.C.F.  Lond.,  2,  Kins;iUnd 

mad,  B. 

1889  Oliver,  James,  M.D.,  F.R.S.  Ediii.,  IS,  Qordon  square, 

W.C. 

I8A4    Ophnshaw,  Tbohas   Hokrocks,  M.Q.,  M.S..  21,  Govcr 

street,  W.C. 
1869     Obd,  George  RirE,  Sirratliam  hill,Siirrcy.     Council,  I8H1. 

1890  Otft,   A.  AvLMER,  M.A.,  H.B.Oxoii,,   204,   Enrl's  Court 

road,  W. 

1880    Orion,  Chablgs,  M.D.,  Nelsoa   pUce.  Neweaftlle-ucder- 
I-yme,  StAffordsbire, 

1890     OsBURN,  Hakold  BiiKUKSs,  L.K.C.P.,  21,  Cedar's  toad, 
Clspham  Conimon,  S.W. 

1877     OsTKRLOH,  pAtL  IluuuLPii.  M.D.  LHpBio ;   Drmdeu 

1663     OavTALD,    JAME3    Wadjjkll  Jcpfbibs,  M.U.,   215,   Ken- 
niagton  road,  S.E.     Trttnt,  4. 

1889*  Paoe.   IIabut   Maruadoks,  F.lt.C.8.,  4,  St.  Mnrgarei's 
road,  Oxford, 


ixii 


rXLLOVS   OP    TUE    SOCIETY. 


JilecleJ 

IGUi    Falmeu,  Johx  Iawin,  47,  Queeo  Aunc  ctreet,  CcveudUh 
ftquatv,  W, 

1886     Papii.lon.Thomas  AlEX*NDEH^  L.R.C.P.  Ed.,  Burley  road, 
Onkliani. 

I877*  Pabamork,  Kichakd,  M.D.,  2,  Gordon  eiquBre,  W.C. 

1867*  PabK8,  JoriN,  Bnuk  House,  MaacUester  road,  Bury,  Lauci- 
Bliire. 

I8d;     Parsons,  John  Inolis,  M.D.'Durli.,  3.  Queen  atr«et,  May. 
fair.  W. 

ISSQ     FAiiaoK9,  SiuvBV,  7S,  Keiifiingtou  PatIc  rond,  W. 

iB8S)     Parsons,  Tuomas  Euwakd,  Paddock  Hoiwe,  RiJgeway, 
Wimbledon,  S.W. 

1805*  Patkrson,  Jamks.  M.D.,  Haybuni  Bank,  Particle,  GlaBgoi 
l8Sli*  PjSACHr,  William,  M.B,,  21-1,  Lewisliam  High  road,  S.IS. 

1864     PsABttoN,  David    ltiTCiii&,  M.D.,  23,   Upper  Piiillimore 
place,  Keiiaiiigtan,  W. 

18/1     Pedleu,  GeoiLOE  Henry,  G,  Trevor  terrace',  ilutland  gate, 
S.W. 

1880  PBi>LEY,TiiOMAsFaANKLm,M.I),,Ilttngoou,Indin.  Tram.  1. 

1881  Perigal,  AitTiixjR,  M.D.,  New  BanieE,  IlorU. 

Iti7l     p£R.Kiao,  James,    M.D.,    IfiS,    Bleury    itrcet,    Moutreal, 
Canada.     Ifon.  Jmc.  Sec. 

1H79*  PesikaKa,  Hokmasji  DoaAiiiiAi,  23,  Huniby  ruw,  Boinliay. 

1883     Pettu-ek,  Epmi'M)  Henuit,  3J,  Slokc  Ncwiiiglou  green,  N. 

187S     PUIBBS,  llOBEKT  b'EATUKUSTONK,  M.E.C.?.  Kd.,  130,  Elgiu 

Meiiiie,  W. 
1879     Phillips,  Geohoe  Uichahu  'rtuNEK,  24,  Leinster  <qu«re, 

Baj-BWHter,  W.     Council,  1891. 

1882  PiiiLLiFs,  John,  il.A..   M.l>.  Canlab.,  M.R.C.P.,  AsaUtiuit 

Ul>8lctnc  Pliyticiau   to   Kiag'*  Cvllcrge  Uuspitnl;  71, 
Grosvenor  atreet,  W.     Council,  1S87-9.     Trotu.  d, 

1891      PHlLLlfs,  W.  E.  Pjcton,  lO.yioaiie  Urcet,  S.W. 


FELLOWS   OF    THE    BOVIKTY. 


zliii 


1878     Pbilpot,  JosKPU  Hkkkt.M.D^  13,  South  Eaton  place,  8.W. 
CWnriV,  1891. 

1871     FHiLPa,  Pqiut  Ogorcs,  21,  Uuvacll  rontl,  Kentingtou,  W, 

1876    Piojtiip,  P.  KiHKPATniCK,  M.D.,  5»,  Abbey  road,  Si.  Jwhn'n 
Wood,  N.W. 

1874    Pioc,  TU0MA3,    M.D.,    M.R.C.F.,  iligb   Leam,  BeUiiRio, 
Kut  Oriiiiiteiiil. 


1889 


1889 


PthitoiiN,  RiciiABU,  L.K.C.P.  Lond.,  &,  Cambridge  lerrncr, 
Dover. 


PLATrAiK,  Davtd  Thomsok.  M.D.,  C.M.Edio.,  Redwood 
Hoiiw,  Bromley,  Kent, 

1864*  Pi-A-TFAia,  W.  S..  M.D.,  liL.D.,  P.R.C.P.,  Pkyiieian. 
Accoucliinir  to  U.I.&  R.K.  the  DucUee*  of  Bdinliiirgh  ; 
Professor  of  Obfllelric  Medieiiie  in  Kiug's  College, 
and  Obstetric  PbyMcian  to  Kinf^'i  College  llospitnl; 
31,  George  ulreet,  Hniioper  jtqunre,  W.  Council,  181)7- 
1883-5.  Ifon.  Librarian,  186S.9.  Hon.  Sec.  1S7U- 
72.     Fice-Pret.  lH7.'J.r)-    Prti.  1879-80.     Trans.  U. 

1880  PocooK,  Fueubkicx  Ekkest,  M.D.,  The  Limeti.  St.  Miirk'H 
rond,  Noltiug  liill,  W. 

1883     PococK,  Waltek,  Gwydyr  HouiC,  .18,  Brixton  bill,  8.W. 

1B63     PooK,  WiLUAX  JoiiK,  L.K.C.P.,  2.  Hemingrord  roAd,  N. 

1876  Poi-K,  H.  CAMrsBl-L.  M.P..  F.K.C.S,,  IJroomagroTe  Villa. 
280,  Goliibawk  road,  Shepherd's  Bu«h,  W. 

1888  PoPHAM.  Robert  Bkooxs,  L.R.C.P.  &  S.  Ed.,  67,  Bartho- 
lomew road,  Camden  road,  N.W. 

1862     PORTBB,  JosEru  Fbanois,  M.D..  Helmiley,  Yorkshire. 

1864  PoTTBB,  Jons  BaPTiste,  M.I)„  F.R.C.P.,  Olmtplric  Pliyai- 
cian  to,  and  liccturer  on  Midwirery  and  DIbcmi?!  of 
Womcii  at,  the  WvatRiiuvter  Hoiiiilfll  i  20,  George 
■trctl,  HaiiOTCr  iquare,  W.  CovnfU,  1872-6,  lt(90-91. 
ffM.  it«.  l«77-8.  TiM-Pi-e*.  ]87it-81.  TfMs.  ]S82'i. 
liMtrd  Exam.  Mu!mw$,  I883-'1.  Prt*.  I8rti.fi. 
Tran».  \. 

1876     Powi>K£LL,  JoHy,  16(1,  Bustou  road,  N.W. 


sUr 


rSLLOWS   OP    THE    SOCIETY. 


Eltffini 

1884^  Powell,   John    Jaueb,  L.R,C.P.  Lond..  Norwood  Lodges 

Wtyb  ridge. 
1863     Powell,  Jo*iaii  T.,  M.D.,  347,  City  rond,  E.C. 

1885  Praeoek,  Exil  Aunold.  Naoeimo,  firitiah  Columbia. 

1886  FitiKatZY,   IIssrv  Soav,  L.R.C.P.  Lond.,   16(1,    Anerle; 

roBd,  Anertey. 

1889  pBATT,  Oeokqb  a.,  The  Willowa,  Wiiterloo  nmd.  Wolrer. 

hataptou. 

1880*  Pkickktt,  Marmaduke,  M.A.Cantab.,  M.D.,  Pliyi>iciftii  to 
the  liJninaritan  Hospital  i  12.  Uevonpoit  stneet,  Glou- 
cester equare,  W. 

O.F."  Pkiestlet,  William  0.,  M.D.,  LL.D.,  F.E.C.P.,  CouaiUtiDg 
Obitelric  Physician  to  King's  Collrge  Hosfiital;  17, 
Hertford  street,  Mftyfnir,  W.  Council,  18.')9-61,  IHfiJ- 
6«.     Ftce.pre,.  IH67-6&.     Pre9.  IS7J-76.     Trant.  6. 

|S7fi*  QuiitKK,  JQSEPH,  L.R.C.P.  Ed.,  The  Oaklands,  Hunter'a 
road,  Handswortb.  BirmlDgltaii). 

I8r>l  Rasgh,  Adolphds  A.  F.,  M.D.,  PhyaiciaQ  for  DiseaMt  of 
Women  to  the  German  Hoapital ;  7,  South  street,  Fina- 
bury  6qQar«,  E.G.     Council,  1871-3.     TVom.  6. 

1878  Uawlinos,  John  Aoaus,  M.R.C.P.  £d.,  4,  Northampton 

terrace,  Svauaea. 

1870*  Bat,  Rdvtabd  Revkolds,  Dulwich,  S.E, 
I860*  Uaywer,  John,  M.D.,   Swalcdale   House,  Quadrant  road 
nnrtli,  Higbbury  New  park,  N, 

1879  Read,  Tbomas  Lacrekce,  II,  Peterabnm  terrace,  Queen 'a 

gate.  8.W. 
1874     Reek,  William,  Priory  Kouae,  129,  Queen's  crescent,  Haver- 
itock  liill,  N.W, 

1890  Beid,  Goufrex  Forkest,  M.U.  Dubl.,  Beibklieiu,  Oraogc 

Free  Stale,  Roiilh  Africa. 

11*79  Eeid,  William  Luluox,  M.D.,  Profeisor  of  Midwifery  and 
Diteasee  of  Women  and  Cbildreu,  Aiideraoa'*  Collage; 
Physician  to  tin;  Glasgow  Maternity  Hospital ;   7,  Royal 

crcficeiit,  QlHB^aw, 


rBI-LOWS   OP    TBK    SOCIETY. 


zIt 


Sleeted 

1889  Rehfrt,  Lbokakd,  M.A.,  M.D.Caatnb..  0.  Hcrirortl  Btrect, 
May  fair,  W. 

1889  RxNTOUL,    RoHKttT    Reii),    M.l).,   78,    Hiirlington    road, 

Liverpool, 

1875*  Key,  Ecioexio,  M.D.,  3fl,  Via  CavoHr,  Turin. 

1890  Retsoi-DS,    Joum,    M.D.Briu,.    SC9,    Coldliurbour    Iniie, 

Brixlon,  S.W. 

tfi^G    RicHARUsoK,  Thomas  AftTHua,  87,  London  road,  Croydon. 

1872  RiCHAKlisos.  William  L.,  M.D.,  A.M.,  Professor  of  Obs- 
tetrics ill  HitrTBrtl  Uiii»tTBity  ;  PliysitiMn  to  tie  Boalno 
Lying-in  lIoBpital ;  225,  Conimonwrnltli  avenue, 
BoatOD,  Mattftcliuictts,  U.S. 

1889  RioiiMosu,  TiTouAS,  1j.B.C.F.  Ud.,  26.  Burnbank  terrace. 
Olaagow. 

1688  RlDlNO,  WlLUAM  Stebr,  M.D.Ediii.,  Buckerell  Lodge, 
lloniton. 

1872  RiODEN,  OEOBOt,  Sar£«on  to  the  Canterbui-y  Dispensary ; 
60,  Burgale  Btreec,  Canterbury.  Trana,  1.  Hon.  Loc. 
See. 

1871  RiouEN.  Walter  16.  Tburloe  place.  S.W.  CounciV,  1682-3. 
Trana.  1. 

O.P.*  Roberts,  David  LtotD,  H.D,,  F.R.C.P.,  F.R.S.  Edin., 
Obstetric  Pliyiiciati  to  ibc  MaiiclieBler  Kuynl  Infirmnry  ; 
aud  Lecturer  on  Ctiuical  Midwifery  and  the  Dieeases  of 
Women  in  Owenit  College  ;  1 1,  St.  John  street,  Dfvnna- 
gate,  MunchcBter.  Council,  1868-70,  1880-2.  rice. 
Free.  1871-2.     Trana.  5. 

1867*  Roberts,  Datid  W.,  M.D..  56,  MaucUester  street,  Han- 
phester  Bqtiarp.  W, 

ID    RoBtBTS,  HuoH  JoNii,  Sc*  Vifw,  Penyftrop*,  R,S.O.,  N. 

Wal«s. 
1883    BoBEKTS,  JoHW  CoETTOM,    L.R.C.P.  Ed.,   A»cnue  House, 

FeclcliRm  rye,  S.E. 
1874     RoBiBTSos,  William  Bohwick,  M.D.,  St.  Aone'e,  Thurlow 

park  road,  Wcat  DuUicb,  S.K 


xW 


rELLQWS   or    THK    SOCIBTY. 


1890  EoBiNSOS,  Abthub  Hesby,  M.D.Dnrh.,  The  Infirmiry, 
Buneroft  roiid,  S.E. 

1887  Robinson,  Hugh  Shapteh,  L.R.C.P.  Ed,,  12,  North  Bridfte 
street,  Motikwearuioiith,  SiiDdcrlsnd. 

1884  BoBiM&OM.  Luke,  M.R.C.P.  Load.,  217.  Geary  itireeL,  Sun 
FranciBco,  California. 

]89l)     RoBSON,  A.  W.  Mato,  F.R.CS.,  HitUry  plnco,  LpsJi. 

1S86  Rob,  Abthcr  Dimvii.le,  B.A  ,  M.B.  CHiitnb..  West  liill, 
Wnnd-worth,  S.W. 

1876     R-OK,  John  Wituixotom.  M.D.,  EllcKmere,  Sniop. 

1874  Roots,  William  Hewiiy,  Canbury  llounc,  Kingitoo-on- 
Tliames. 

Ifl74     lloPBH,  AUTHUK,  Lewishnm  lull,  HlBClfhenlli,  S.E.    Couneti, 

1B&6.8. 

1965*  ROFGB,  GcoROKj  M.P.,  CoutnltiDg  Pliysicinn  to  the  Itnyat 
Maternity  Charity;  Oulton  Lodge,  AyUiinm.  Norfolk. 
Council,  1875-77,  1883-5.  Vice.Prea.  1879-81,  1883, 
Board  Exam.  Midwivea.  18S0-I,  \%m.b.      Tram.  10. 

lysg  R03>,  Henry  Coopbb,  M.D.,  Penro»c  House,  linnipatcud, 
N.W.     Covncil.  1875-77-     Tram,  4. 

1887     RosENiU,  Albert.  M.D.,  Weberganse,  l.i,  Wienlndcn. 

1880     Roaa,  David  Palmek,  M.D.,  FrGptown,  Sierra  Leone. 

I8S3     RosSRii,  Wai,tkk,  M.D.,  I,  Wcllenley  ^illaa.  Croydon. 

1884  Ro33iT£B,   GnoiioB    KRBrcRrcK,  M.U.,    Suri^eou    to    the 

WeRton-Buper-Mare  Hoapita.!;  Cairo  Lodge,  Weaton- 

anper-Mare. 

1885  RoOOKTON,   Edhond  WlLKlNSOK,   M.D.,  3;).  "WeBtbourne 

terrnce,  W. 

IS84  RoDOHTOH,  Walter,  L.B,C.P.Load.,  Cranborn^  Hoaie, 
New  Barnct. 

1S82  RouTir,  AiiANU,  M.D.,  B.8.,  AaniatRnt  Obitetric  Phyaicinn 
to,  Riii  Teaclier  of  Practical  Obstetrica  and  Gynaecology 
at,  Charing  Cross  Hoapitnl ;  Ha,  Manchcaler  aqiinn, 
W.     Qounctl,  I8S6-!J     Irant,  2. 


rBLLOVB  or  THX  80CIBTV. 


xMi 


Kleeled 

O.F.*  RonTH.CH&nLEs  Hekrt  Felix,  M.U.,  ConMtlling  Pliynicinn 

lollieSntBnritan  Free  lloapitnl  for  Wompii  ninK'iiildrrn  ; 

52,  Mantdgu  nqiwre,  W.     Counril,  18."j9-61.    f'ice-i'rea. 

IS74-S.     Trant.  13. 

1887  BowBOTHAU,  IIf.kbkrt  C. 

1887*  Rowi,  Arthur  WiLTOK,  M.D.  Dur.,  I ,  Cecil  stref t,  Margnte. 

1R8I     RovroKTil,  ALfKEi)  Thomas,  Gr«yfi,  K«s». 

1U86  RttsiiwouTii,  FKi.>'K,  M.B.  Loiid.,  Ltnigdnlc,  Qoldliurat 
IcrraCP,  South  Hanipatead,  N.W. 

1888  BcsiiwouTn,  Norman,  Ij.K.C.P.  Loud.,  Be>ecliliel(i,  Wnltoii- 

on-Thniue*. 

1886  RuTHBHrooRD,  Henbt  Ti{otter.  H.A.,  M.B.  Cautab.,  -JG, 
Queen  Anne  street.  Cavendish  square,  W. 

18e6  SaBOIa,  Baran  V.  d«,  M.D.,  Pirectov  of  Hie  Scfaool  orMe<]i- 
citie,  Rio  (le  JHiiriro  ;  3A,  Run  do  Viiconde  Mnmngtia^io, 
Rio  de  Jniieiro.     Trans.  2. 

1883  Saltes,  Fkancis  JoaEm,  L.R.C.P.  Ed.,  9,  tyddon  terrace, 
Leeds. 

1864  Salteb,  John  H.,  D'Arcy  Houkc,  ToLIeahunt  D'Arcy,  Kel- 
rcdoti,  Ebbcz. 

187^*  Salimajim,  Frederick  William  ;  Senior  Snrgeon  to  the 
Ho«piUl  for  Women  ;  97a,  Monipellicrrond,  Brlj^litun. 
Ccttneil.  lfl80-'2.     flon.  Loc.  Sec. 

1868*  Sams.  John  Suttoh,  St.  Pettr'e  li«dge,  Eltlinm  road,  Lee, 
8,E. 

1886  SAKDsasos,  Robert,  M.B.  Oxod.,  3'S,  Montpellier  road, 
Brighton, 

1872    Samqstes,  Ciiarlbs,  MS,  Lambeth  road,  S.E. 

1870     SaOLjWiluau,  M.D.,  Lyndlhorpe,  Boncombp,  Bournemoiitb. 

18dl  Saunders,  Fkbdkuick  William,  M.I).,  n.C.Caiitab,,  I7t 
BMktton  garden*,  Sontli  K*n»ington,  S.W. 

1872  Sataoe,  Tqomas,  M.U.,  Surgeon  to  ibc  Birmingham  and 
Midland  IIospttaL  Tor  Women;  3;^,  Nevhatl  street, 
Birmiugham.     CotineU,  1878-tiO. 


xiriii 


rexxowa  op  tbe  sociztt. 


BUeud 

1877  Satobt,  Chaklzs  Tozkr,  M.D.,  6,  Douglas  rond,  Canon> 
bui7,  N.     Traiu.  \, 

1890    ScBACQT,    Fit&!iK  Fardertck.    B.A.,   M.B.Ciatab.,    168, 

Earl'i  Court  road,  S.W. 

Ilj70     Scott,  /oH^,  M.D.,  New  street,  Snndvicb. 

1868  Scott,  pATaioK  Ccuin,  B.A.,  M.B.  CfiDtab.,  38,  Stioater'a 
UiU  roAd,  BlAckhcAlb,  S.£. 

1866  S8(jiii:iBA,  Jaueh  Scott,  OB,  Lemsa  street,  Goodman's 
fields,  B..  niid  Crescent  House,  CasaUod  crraccnt. 
CMnlaud  rond,  South  Hnckiiey. 

1882  SEftJEAXT,  David  Macbice,  M.D.,  1,  Tbe  Terrace,  Cam- 
brrwell,  S.E. 

1875  SiTON,  Daviii  Elphinstgke,  M.B.,  1 10,  Cromvcll  road, 
8.W.     CWrciV,  1884. 

I860  Sbweix,  Csablzs  Dbodie,  M.D.,  21,  Cavendish  square, 
W.,  and  13,  Fenehurcb  street,  E.C.    CouRcil,  i880-'i. 

1887  SsiNNON,  R.  AlEXANUEB,  L.11.C.P.  Ed..  Croftoti,  Orping- 
ton, Kent. 

O-F.  Shihpis,  Henuy  WrLsoN.  P.B.C.S.,  Surgeon  to  the  Bed- 
ford Oeoeral  lufirmary,  Bedfi^rd.  Council,  IS7I-3. 
Trant.  i .    Bon.  hoc.  Stc. 

1887  SuAff.  Joi<»,  M.D.  Lond.,  Obstetric  Ph^MciBn  to  the  North 
West  London  Hoipital ;  S'l,  Queen  Antie  street,  Caveti- 
diah  aquare,  W.     Tranx.  I. 

1B67  8ucpUERi>,  Fkedsbick,  UB.C.P.  Ed.,  3S,  King  Hear;'* 
road,  Primrose  hiU,  N.W. 

1890     SniLLiNGFOBD,  Hesey  Baetlett,  llf,  Pecfehftm  Rye,  S.E. 

18S0  Silk,  Joriu  Fbebehick  William,  M.D.  Loud.,  6,  Chando* 
alreei,  W. 

1886     SiUUOHS,  ForBNEdS,  M.B.Edin.,  Brisbane,  Queensland. 

1874  SiSclAfK,  Alexander  DoutL,  M.D.,  ConsHltiiig  PhysmaD 
to  the  Boston  Lying-in  HospiiRl ;  35,  Newbury  atreet, 
Boston,  Mnsaacbiieetts,  U.S. 


rKLl^WS   OP   THK    MOCIETV. 


xlix 


Elected 

1868  SiNCLAitt,  William  Japp,  M.D.  Aber.,  Hoiiornry  Pliy»icmri 
to  like  Soutlieni  HoAp'ilnt  for  Woineu  ftad  CliiLdrcn  ant] 
Maternity  Ilnspilnl.  Maiiclieetcr ;  nnd  I'rofcMor  of 
Obftletric*  and  Gynecology,  Owena  College,  Msn- 
dieitpr;  2tiH,  Oxford  ruud,  Mnncbts'tr. 

1878     SUOHT,  Geobge,  M.D.,  .'t,  Clifford  sirwt,  Bond  sircer,  W. 

1881  Sloan,  Akchhillij.  M.B.,  27-2,  Bnth  ilrcct,  Glasgow. 

1876  Sloak,  Sahcel,  M.D.,  CM.,  5,  Somerset  plnce,  Snuclncliiill 
street  West,  Glasgow. 

1890  Sloua>-,  FKKDEicicK,  Uowiirord,  97^,  Mootpellier  road, 
Brigfatoii. 

1861  SlthjUT,  William  Davtisl,  26,  CiiverMliain  road,  Kentiiili 
Town,  N.W.     Couneii,  1H91. 

1867  Smith,  Hetwood,  M.D.,  16,  Hurley  streci,  CftvenilinU 
nqiinre,  W.  Council,  I8/2-4I.  Board  Exam.  Midtotces, 
l«74-76.     TraM.  fi. 

1885  Smith,  Howabw  LroM.  L.K.C.l*,Lond.,  Buckland  Home, 

BuckUud  Ncwtuu,  utBr  Durclifntfr. 
1890     Smith,  llcoii,  M.D.Loud.,  36,  Bow  RonO,  E. 
1875     Sunii.  Kiciuni)  Thomas,  M.B.,  I'hvMcian  t«  the  Ho»piinl 

for  Women,  Solio  equare ;  ;j3,  llaverstnt^li  liill,  N.W. 

1886  Smith,    Samuel    Paeboxs,    L.K.Q.C.P.I.,    Park    Hyril, 

Addi«coni>i4>  ronJ,  Croydon. 

l8Uli  Sunn.  Stupueh  Maberlx,  L.R.C.P.  Ed.,  Yarra  street, 
Geelong,  Melbourne.  [Per  Henry  31.  Snaitli,  Holly 
Lo(Ig«,  CItilliiigton,  Kiugobridge,  Soiitli  Devon.] 

IB/y  Shitu,  Wm.  Hdcu  MosTcoMEbty,  UK.C.P.Ed.,  2^,  London 
road.  Wert  Croydon,  Surrey. 

1676  Shell,  Edmund  Guokob  Cahrvtbbrs,  10^.  Bonner  rond, 
Violorla  park,  N.E. 

1882  Skell.    Geoboe,    L.R.C.P.  Bd.,  Fort    Canje,  Berbic«,   B. 

Guiaoa. 

1889  Solly.  Ervest,  M.B.Und.,  F.R.C.8.  Kng.,  79.  Lambeth 
Palace  road,  S.I-:. 

I B68    SpaI! iL,  BAK!<Aai>  B..  1,  Staitwick  road,  Weit  KeuftiugtOD.  W. 
TOL.  XXXJl.  d 


3 


FKLLOWS    or   THK    HUCIETY. 


BlecUd 

1888  Spencer,  Herbert  R..  M.D.,B,S.  LonJ.,  Awistant  ObaUtric 
Phyticiaii  to  I'liiTersity  College  IlDspital;  10.  MnnB- 
field  Rtrcet,  CaveiiiiUli  aquare,  W.  Council,  1890-91. 
Trans.  I. 

18?6  Spe.vcbh,  Lionel  Dixon,  M.D„  BngsJe-SurgeoB,  l,M,S., 
liengn.!  EelnliliahrucDl  [cnre  of  Messrs.  GniidlBV  Rnd  Co., 
55,  Pnrlinment  atr^'et]. 

mS'J  Spoon  en,  Frederick  UENax,  M.D.,  Maillaad  Lgtlgc^ 
Cliipton,  N.E. 

1876  Spl'bgin,    Heubert     Brakwiiitb,    8i',    Abiiigtou   stitcl} 

Nortkamplon. 
1884     StaNsby,  CnAPtRS  John,  M,D,,  10,  Stran^il,  Derby. 
ISSG     StEAVBKsoN,  VViLLiAU  Ii!uTrABt>,  M.D,  Cantab,,  M.B,C.P., 

15,  Mansfield  street,  W.      IWnt.  i. 
It)84     Stevenson,  Esmoj^d  Sinclair,  F.R.C.S.  Kd.,  Strathdian 

House,  Rondeboseh,  Ca-pe  of  Gaoi  Hape.     TroTtt,  I . 

1877  SxErHENSoN,  Wn.LtAM,  M.D.,  Professor  of  Midwifery, 
lIiiireTBily  of  Aberdeen;  'l^T,  Union  Street,  Aberdeen. 
Coancii,  1881-3.     Fice.Pres.y  1^87-89.     Trana.  1. 

1W73     STEWAaT.JAMEs,  M.D. ,2,  Skinner  street,  Whitby,  Yorkshire. 
1875*  Stewart,  William,  F.E.C.r.Ed.,  Dyrock  ColUge,  Frcit- 
wiclf,  near  Ayr,  N.B. 

I68'l     SnvEN,  Edwabd  W.  F.,  M.D.,  The  Manor  Lodge, Harrow. 

mB4  SriyeMS,  DebtkaM  II.  LrxE,  II,  KetisiDgtan  gardeua 
square,  W. 

1883  Stocks,  Fueuebick,  421,  Wauditrortli  road,  S.W. 
1866*  Stramib,    William    Heath,    M.D.,    2,    Belaiie  aveDue, 

EeleiEC  park,  N.W.     Council,  1862-4. 

Id7l  Stueoes,  Mortabue  J..  M.D.,  The  Limea.  Beckenliaim, 
Keut. 

1884  SuMDEBLiND,  Septiuds,  M.D.,  155,  Gloacffiler  road,  South 

Keusitigtoi),  S.W. 

1886  SuTCLifFB,  AicTHVK  Edwin,  Cliorllon  Ludgc,  Stretford 
road,  Manclieater. 

1883*  Sdtiieblaku,  Heniv,  M,A,,  M.D.  Oxon.,  M.R.C.P.,  f, 
Riclimond  terrace,  Wliitehall,  S.W. 


rBLLOWS   OF   TBE    SOCIETY. 


Elected 

1^88  ScTTON,  John  Blakd.  P.R.G.8.,  48,  Queen  Ann«  atreet, 
Cavendish  sqiiBTC,  W.     Trans.  1 . 

1859*  SwAYSB,  Joseph  Griffiths,  M.D..  PUysician-ApconcIieur 
to  the  DriMol  General  HoHpiui)  ;  Karewootl  Uouhc, 
74,  Peinbrokt  road,  Cliflon,  Bristol.  C</mcil,  1860-51, 
Viee.Pre:  1862.64.     Tram.  9,     Hm.  Loc.  See. 

1888*  SwOBV.  llENBV  Ceoboe,  L.K.Q.C.F.  &  L.M..  IC,  Albion 
road,  Holloway  rond,  N. 

IVtT,  Edwabo  Sabink,  M.D.,  48,  Iliglibur;  park,  N. 
Tram.  I. 

TaIT,  E&wakd  W.,  48,  Highbury  park,  N.     Cuuneil,  1886-7. 

Tait,  Lawbos,  F.R.C-S.,  Surgpoii  lo  ilie  Biritiingliniii  nnd 

Midland  UoBpitai  for  ^VoIncu  -,  7,  The  CreBcenl,  Bif' 

nutigliftm.     Trant.  12. 

Taxaki,  Xanaheisu,  F.K.C.S.,  10,  Ki»lu-Konyacbo,  Kio- 
bashikfl,  Tokio,  Japnn.     Hon.  Lee.  Stt. 

TAJiKEii,  John,  M.U.,  F.L..8.,  PliyRician  for  DiRcaieH  of 
Women,  to  the  Fftrriiigdon  General  DiKpi-nsary;  (9, 
Queen  Anne  street,  Cavendisti  iquaro,  W. 

Tapsob,  Alfkeu  Joseph,  M.B.  Lond  ,  J6,  Glouceeter  gnr- 

dens,    Westboume    terrace,    W.       Council,     1862-64. 

Fice-Pres.    1891- 
Tapson,  Josspit  Alfbed,  Surgeon  to  the  Claphim  General 

Dispensary ;  Hulmwood,  Tlie  Gro^e,  CUpliam  common, 

9.W.    Trans.  1. 

Tayleb,  Francis  T.,  B.A.  Loud.,  M.B.,  Claremont  villa, 
224,  Tjewisbam  high  road,  S.E. 

Tayloo,  John,  Knrl'a  Cclne,  Hulntenit,  Bti«. 

Tatlob,  John  W.,  M.D.,  D.Sc,  Ratbuy  Ilou^e,  Prince  of 
Wain  terrace,  Scarborough.     Hen.  Loc.  Sec. 

1690*  Taylob,  John  Wiullm,  F.R.C.S.,  b%  BatJi  street,  Bir- 
mingbam. 

TitijOK,  WttLiAU  Cbables  Rtebley,  M.R.C.P.  Edin.,  M, 

Qn«en  atreet,  iicarborougb. 
Thomas,  Bbkjamis  Wilfbeu,  L.R.C.P.  Lond.,  Welwyo. 
TflONAB,  OeoBOE  li.  W.,  Orchard  liouae,  Teignmoutb. 


1883 

1879 
1871 


laso 


1871 


IS&9 


I8«3 


1871 


1869 

n 


ie8» 


lii 


FELLOWS    01'    THE    S(>CI  ItTT. 


EUelfd 

1887  TuoHAN,  William  Eduund,  L.a.C.P.  Ed.,  Bridgend, 
Qlamorgaiiiliirf. 

1882  TiioUAs,  Hugh,  TIr>  Grange,  Coventry  rond,  Qirminglinin. 

Iti90  i'HOMPso.v.CiURLXS  (Ibrbbut,  U.A,.  M.D.  Dubl.,  'iX,  Ualf- 
moon  alreet,  Mayfnir,  W. 

1867*  TnoMPSoy,  Jobepr,  Ij.R.C.I'.  LohH.,  I,  Oxrord  »treet, 
Natliiiglinm.     Tratu.  1.    Hon.  Loe.  S^e. 

1978  TuousoK,  Davji),  M.1>.,  37,  t'nttle  atrcct,  Luton,  Bedfonl' 
shire. 

1874  TuouaoK,  Willum  Sinclmii.  M.D.,  CM.,  F.R.C.S.Ed, 
I,  Palace  court,  Notling  liill  gdte,  W. 

1879  TnoBSTON,  J.  SxowatEY,  M.B.,  CM.,  Surgeon  to  tlie 
S.imflritan  Free  lIoBpiCal  for  Women  and  Cliildren,  22, 
Porlmari  mreel,  Poriman  Rqufirr.  Councii,  1S82-3. 
Jlm.Lih.  iSfi^-5.  Hon.  See.  1.H86.  FicePnt,  188fi. 
Trant.  G. 

1874  TiCKHLHsT,  AuouDTtia  RowLANO,  SilHietUT  HouBp,  Prreii- 
eey  road,  St.  Lconard'e-oa-Sen. 

Ifl73     TicEiiUKST.  CiiAHLKS  Sage.  Petersficld,  ITanra. 

I86fi     TiLLET,  Samuel,  6,  Down  stri-et,  Piccadilly,  W. 

O.F.     Tilt,BdwaiidJoun,M.D.,  CaniultingFliyiieinn-Accoaclieiir 

•to  the  Farriiigdon  General  Disjiemary;   27,  Stjmoiir 

■tri-et,  Forlrnaii  square,  W.      Council,  ))S67-68-     Fici' 

Pret.     1859-70.        Treat.     1«7U2.       Pm.     18?3.4. 

Trnnit.  "■ 

1883  Tinker,  Fredkrick  How^ss,  P.R.C.P.  Ed.,  Tnlbot  House, 

Hyd<>,  Chcahiiw. 

IH87     TlNtEV,  Thomas,  M.I).  Uiirli,,  Hiidcgiitd  House,  Wliiiby. 
1679     TiTY,  WiiXUU  J^UHS,  F.R.C.iJ.  tid.,  3.  LsiiBdovn  placr. 
Clifton,  Bristol 

1872  T0LOT3CHINO7F,  N.,  M,D.,  Charkoff,  RuMia. 

1884  Tbavebs,  William,  M.D.,  2,  PiiiUimorc  gurdcna,  W. 

1873  Tbbbtiail,  Henry    Ebnt.8T.    F.R.CS.  Ed.,    M.R.CP.Ed., 

3€,  Westbouriic  gardeni,  GUsguw,  W.     Trana.  1. 

1886  TOCKETT,  Waltbh  Rboinald,  Wfsl  Kent  General  Hospital. 
Maidaloiie. 


FSUOVTI  or  TBB  KOCIBn. 


liii 


EUeted 

ltiG5*  TCHXER,  John  StoNKT,  Stanton  Home,  HI.  Anerlry  roAd, 

Upper  Nonrood. 
1881     ToHiu^    PuiNK.is    Bahkktt,    M.I).,    SiAlion     Iloapital, 

Oibraltnr. 

1861  TircKD,  JouK  James,  Junr..  V'.K.C.S.,  14,  Upp«r  Brook 
ilreet,  W. 

1890     Tykhki.1-,  Waltkb,   L.ll.C.P.IiOiici,,  95,  Cromwell   road, 

S.W. 
1874     ViSM,  A-LBKBT  Joiix,  M.D.,  Olintttric    PbyBicinn    lo  the 

MelroiKititKii  Free  Hospital ;   \'2'2,  llarlcy  Kireet,  W, 

1873  Vb&lev,  KkoinaU)  Luuis,  I-'.R.C.P.  Ed.,  2tfB,  Uevonkliire 
street,  PorlUnd  pUce,  W. 

1S79     Waoe,  Gcorgs  Hekhbiit,  Ivy  Lailgr,  CliiBlelntnit,  Kent. 
I860     Walks,  Thomas  CAKKErs,  Dawnham  Mxrket,  Nnrrolk. 

1666  Walker,  Tiiouas  Jambs,  ^l.U.,  Suri;coii  lo  the  Geiirrnt 
infinniiry,  Peterborough  ;  33,  Wentgatp,  Pctcrborougli. 
Vovneit,  1878-8U.     Boh.  Loe.  Sec. 

1889     Wallacb.  AbbaHak.  M.D.  Edin,,  fi-l.  Unrley  ilrcct.  W. 

1870  Wailacb.  Kkedkrick,  96,  Caaenove  road,  Upper  CUplon, 
N.     Couneii.  1880.2. 

I872*  Wallace.  Jobs,  M.D,,  AwiiBtniit-Phyaiciaii  to  the  Iiivcrponl 
Lying-iu  Hospital ;  1,  Gfimbier  terrace,  Liveq}oul. 
n<m.  loe.  5«.     Council,  1883-5. 

1883  WaLIacii,  RicuaKU  UtJiaANK,  M.B..  Cravruhumt,  Craven 
pMlc,  Stamford  liiU.  N. 

1879*  Waltr*.  William,  M.A.,  M.D.,  Surgeon  lo  St.  Mnry*. 
Iio«pilal,  MancbeflUr ;  20,  St.  John  street,  Miin- 
chesler. 

1867*  Waltbbb,  JAHEa  HofKlNs,  Surgeon  to  (lie  Royiil  Berkihirt 
Hoipita] ;  15,  Friar  Blrt-ct,  Reading,  Berka.  Council, 
1B84'6.     Tram.  1.     Bon.  Lac.  Stc. 

I8"3    WaiTEBS,  JOBN,  M.B,,  Church  ttrcet,  Reigate,  Surrey. 

1886  Wake,  aBOROE  Stephrx,  L.R.C.P.liOnd.,  NpwtownfielJs, 
Caralialtou. 


liv 


TELLOWS    OF   THE    SOCIETY. 


Eieeted 

IS62     Watkins,  Chablbs   Stetfabt,  16,   King  Willumi   street, 

Sinind,  W.C. 
Watson,  PuRcrvAi  Humble,  L.E.C.P.  Lond.,  72,  Jestnoiid 

road,  Newcantle-oa.Tjiie. 
Wadgh,   Ale\an»kb,   L.K.C.P.  Lanil.,    Midsomer-Norloii, 

Batli. 
Webb,  IIabut    Sfeakman,    New  place,   Welwyn,  Uert*. 

Oomcil,  1889-91. 
Webbeb,  William  W.,  L.R.CP,  Ed.,  Cr<'wkcrrie. 
Wedmore,    Ernest,  M.B.  Oanlab.,  Obstetric  Physician   to 

ibe    Itriilol    Ruvnl     Iiirirmary ;     1 1,    Iticbirond    lUll, 

Ctirtoii. 
Weir,  ARCinBAtn,  M,IJ.,  St.  Miimgljo's,  Great  Malvern. 
Wbllb.    Albebt    PRiMitosE,   M.A.,   L.R.CP.  &S.,  L.M., 

Bourneville,  ijclion)  rond,  Beckenhnm. 
Wklls,  Kbank,  M.D,,  Hftwes  aireel,  Brooklinc,  MnsBacha- 

setlB. 
Wells,  Sir  T.  Spekckb,  Bart.,  F.R.C.S.,  Surgeon  in  Ordi- 

DAty  to  H.M.'a  HouBcliold ;  CoDBiilliiig  Surgeon  to  the 

Bamaritnii  Free  Hospitnl  Tor  Women  nnd  Cliildreii ;  3, 
Upper  GroBvenor  utreet,  W.     Courtcil,   1859.     Fice- 

Prei.  I8(iS-70,     Trans.  5.     Truttee. 

Wb»t,  Gu.vitLEs  J,,  t. R.C.I*.  Loud.,  Bcnmi nater,  EempstiotC 
road,  Sireatham  Common,  S.W, 

Weston,  Joseph  TiiEOfnii.ua,  L.K.Q.C.P.  &  L,M.,  Civil 
Surj(eoa,  Mergui,  Lower  Burmali. 

WliARnr,  RoBBKT,  M.D.  AbeF.,  6,  Gordon  square,  W.C. 

WUABTOS,  llEKBvTiiOBKTON.  M. A.  Oxford, 39,  Sl.Gforge'a 
road,  Kilburn,  N.W. 

WiiEATON,  Samoel  W.,  M.D.Lond.,  52,  The  Ctiaae,  Clap- 

hum  common,  S.W. 
Wheeler,  Daxiel,  Chelmaford. 
Whitcohde,  Cuables  IIeney,  F.R.C.S.  Bdin.,  Westerham, 

Kent. 
White,  Chakles    Pehcivai.,  M.A.,  M.B.,    B.C.Caotab., 

144,  Slonue  street,  S.W. 


1884 

1884 

O.F. 

I88fi 
ISH'^ 


1876 
1887 

1876 

O.F. 


1886 

18S8 

1886 
187E 


niLLOWS    OF   TBB    SOCIETY. 


Iv 


IS90  Whitb,  Edwis  Feascis,  F.E..C.S.,  7,  DeiiUry  road,  Putney, 
S.W. 

1882  Wholey,  TttoMA3,  M.B.  Durh.,  Winchester  House,  50,  Old 

BroAd  street,  E.C. 

I88S  WlCKs,  William  CAiitN-a,  M.B..  Santh  View  House,  Went 
patadf,  NewcaBUe-ou-'r>-ne. 

1887     Wioan.Chablbs  Akthur,  M.B.Diirli,,P«m8head,Somerget. 

1877     WlOMOaB,  WittlAM,  lai,  luveroeas  Irrrace,  ilyde  pnrk,  W. 

1883  Wilkinson,  Thomas  Marshall,  F.R.C.S.  Hd.,  Surgeon  to 

ibe  Lincoln  County  Iloapil&t ;  7,  Linditm  road,  Lincolu. 

1879  WiLLANS,  WiLUAM  Blunubll,  F.H.C.P.  Ed.,  Much  Had- 
Imtn,  Ilcru. 

I87U  WiLLBTT,  CuAHL£s  Vbbuall,  3,  Soutbdown  road,  Shore- 
hnm,  Sussex. 

1889  Williams.  Abthlii  Hevry,  M.A.,  M.B.,  B.C.  CRutab.,  79, 

Ijondnu  road,  St.  lieonard'a-on-Sea. 

1887  WiLUAUs.  Chaules  Rdbsbt,  M.S.,  C.M.Ed.,  15,  Iraaboe 
lerratre,  Asbby-de-U-Zouch. 

1872  Williams,  John,  M,D.,  F.R.C.P.,  Phyniciau-Accuucliciir  to 
Il.S.ll.  Princess  Beatrice,  Priuccsa  Henry  of  Baltcu- 
bcrg ;  ProfcBJor  of  Midwifery  in  University  College, 
London,  ajid  OkMetric  PtiyaicJaii  to  University  College 
Iloapitul ;  63,  Brook  street,  Grosvenor  square,  W. 
tWnciV,  1H".J-;(J.  Hon.  See.  1877-9.  f'ice-Prca.  lSm.2. 
Bounl  Exam.  Miduiivei,  1881-^;  OAairmmi,  1884-fi. 
Pm.  1887-8.     Trcuu.  12. 

1890  WiLUAMs,  Rroisalii  Mdi:io,  H.D.Loiid.,  95.  St,  Mark's 

rood,  N.  KeneingtoD,  W. 

1881  WiLLin,  Jt<UA.\,  M.R.O.P.  £d.,  6-],  Sutherland  avenue, 
Msidii  vale,  W. 

1860    Wilson,  HoBEai  James,  F.R.C.P.  Ed.,  7,  Warrior  sqoarc, 
St.  Leonard's-on'Sea,  Suasei.     Hon.  Loc.  See.     Viet- 
Pnt.  1878.80. 
WiXTEBSorroM,  Artudu  Tuouas,  L.R.C.P.  Kd,,  Lark  hill, 
Swiiilou,  MaticliMlrr. 


Ivi 


FELLOWS   or   TUK    BOGIKTT. 


EUcled 

1877     Wi)iTLK,  Hknks,  M.B.,  Kingtdawii ,  Church  row),  Forest 

M11.S.E. 
(887     WiTfiEHs,  Robert,  Lawrence,  Olago,  New  ZeRlnnd. 

IQyy     WooDWAKD,  G.  i'.  M.,  M.D.,  137.  Urerpaol  etreet,  Sydney, 

New  South  Wftlea. 
1890     WoBKtJM,  Georoe  ?oeteb,  6,  College  terrace,  Bel«i(*  p«rli, 

N.W. 

O.P.  WoRsUir,  J.  Lvc&a,  Mauor  llou»e,  lUvcrhcad,  SeTeuonki, 
Kent.    0)unci7, 1875-77.    TiM-i'i-.M.  l(*h3-5.    Tram.i. 

1H81  WoKTHINCTOIC,  QtiOBOF.  i'tK'CH  JK^K1N;GS,  M.K.Q.C.P., 
Jlighdcii,  Sidcup. 

187<i     WoBTS,  Edwim,  6,  Trinity  5trtet,  Colcl«Bter. 

1887  Wright,  Ciiables  James,  Surgeon  to  the  llnnpUol  for 
Women  and  Cliiidreii,  Li^rds;  Profcaaor  dI"  Midwifery 
to  tlie  Yorkshire  College  ;  Lyntau  Villa,  Virginia  road, 

Leeds. 

IBBB*  WTAiT-8MiTii,FBAKR,.\l.l{.,b.C.Canlab.,  Britiali  HotpiUl. 

Bueaoa  AyrcB. 
1889     WxHTGu,    A»D»EW    Ellis,    L.B.C,r.  Lund.,    SQ,    Upper 

Burkekv  street,  Portmoii  squnrc,  W. 
1871     Yarrow,,  Gbuiioe  Buoeke,  M.l).,  Oakley  Huuse,  317)  City 

roAd,  E.G.     CoanQil,  1S81-:j. 
1882*  Yoi'Ku,  Cii-iKLKa  Gkovb,  M.D.,  New  Amsterdam,  Bcrbice, 

BriLisSi  Ouinaa. 


CONTENTS. 


PASS 

List  of  OfBcere  for  1891  . 

V 

List  of  Presidents            .               .               .               . 

.     vit 

LUt  of  E«ferees  of  Papers  foi- 1891 

.    Tiii 

Slandiog  Oommitteea 

ix 

List  of  B.oaonury  Local  S«cre(ariea 

X 

Tmst^ee  [>f  tho  Societj'a  Property 

xi 

List  of  Honorary  aud  Correaiwnding  Follows 

si-zii 

List  of  Ordinary  Felluvra 

.    Tiii 

Coatvnts            .... 

.    Irii 

List  of  PlaUa  and  Woodoota 

.  Ixiii 

AdreriisemeaL  .... 

.    in 

Hon*  of  Attendfcjici!  at  liibrory    . 

.      llT 

JsnoBiy  8th.  1890— 

Rapidly  f&tikl  CerubraJ  Hffimoirliiige  oocurrin^  in  » 

Case    of    Pregnancy    compUcatod    with    Moltiplo 

Fibroids,  akonn  by  Dr.  William  DrxcAN 
Uanvlmivycr'e    Trnnefusion    Ai)|Mi.rattte,    aliown   by 

l>r.  Uatthetcb  Dokcjik 
Or&riaa  Cyst,  partly  Dermoid,  sliown  by  Dr.  0.  H. 

GlBTEB  ..... 

Two  Dermoid  Oyats  from  tbu  mhhc  puticnt,  ahown  by 

Dr.  0.  H.  UAKTEa        .... 
Lipoma  removed    from   L«fb   LabLum  Maj'us  of   u 

iroman  ugod  forty,  shown  by  Dr.  0.  H.  Oabtbb     . 
I.  Should    Pregnancy    be    terminated    prematurely   in 

Oaaeaof  PhtbieiaP    By  William  Duscan,  M.D.  . 
IT.  Tito  Cues  of  Puerperal  Eclampsia,  eBpecially  illuB> 

mting  the  Tempernturo  and  Urine  in  iLv  Di««uo. 

By  G.  EfcMKHT  Hksuan,  M,B.,  P.B.O.P.. 


17 


February  5th,  1890— 

Annaal  Mooting 

Double  PyuSAlpioi,  shown  by  Dr.  C.  H.  Cabtcb 
VOL.  XXXU.  t 


iTJii 


OONTSNTB. 


Oyatio  DiB«aae  of  the  Oliorioii,  shown  by  Dr.  Auer 

LAWKENce    .  .  .64 

Cystic    DiBdase  (Hydatirorm   Degeneration)  of    the 

ChoFion.  shovm  by  Dr.  John  PaiiLrpB    .  .      65 

T^tenta  s.ad  Appendages  of  an  Infant;  Hte^morrha^ 

from  the    Uteiine    Mucous   Membi-aue,  KbowD  I>j 

Mr.  0.  H.  James  .  .  .  .66 

DturDS  with  Placunla  Frffivia.  shown  by  Dr.  A.  H. 

BOBlBsON  (communicated  by  Dr.  Cui.LlNawo&lB)  67 
ni.  Urelhral  Diverticula.     By  Amakd  Routh,  M.D.  69 

AhduuJ  Meeting:  The  Audited  Report  of  tLe  Tr«a- 

BDMr  [Dr.  Hermak)  .  ■  .  *2.  8S 
Report  of  the  Hoaaraj'y  Librarian  (Dr.  BOB- 

bocks)  .  .  .  ,82 

■         Heport   of  the  Gli&iriuan  ol'  tbe  Boaj'd  for  the 

Erumination  of  Midwivce  ^Dr  J,  Watt  Black)  82,  Si 
• Alteration  in  the  Laws:  Cap.  V— Of   the  Con- 

tribntions  of  FellowB  .  .84 
—  Election  of  OfBcers  and  Council  for  the  yeitr  1880  85 
Address  of  the  PreBident  [Dr.  Qaj.abim)  ,      86 

March  5th.  1890- 

Altemtion  of  Laws  ;  Ghftptet-  SIX — Of  thu  Socicty'i 
Property        .....    ]06 

Chapter  VllI— Of  the  Trustees  .  .    106 

Confirmation  of  the  Action  of  the  Council  respecting 

tbe  L«aBe        ..... 

Bcpart  of  Comaiittee  on  Dr.  Robinson's  Specini>eii  of 

Plucentn  PrBvio,  .... 

IV.  Tbe  Change  in  Si£<>  of   th«   Cheat  and  Abdomen 

dnring  the  Ljing-in  Period,  and  the  Effect  of  the 

Binder    upon    them.     By   G.    EkHKBT    Hebman, 

M,B.Lond..  F.II.C.P.    .... 

V.  Apoplexy  of  the  Orary;   Cyatio  Dilutation  withont 

Hupture.    By  ALBAif  Dokan,  P.B.C.S.    . 

April  2nd.  1«M— 

Living  Female  Child  with  Three  Lover  Limbs.  flLown 

by  Dr.  Godson  .... 

Three  Cases  of  Cougenitjil   Diaphragmatic  Hernia, 

ehownby  Dr.  HjeBBEBTlLSpEHCEB       .  .    132 


I 


^^^^^^^^^^^^H                             ^^^^^ 

^1 

^^^^^^^^^^^ '                                                                                                                 PA3B                ^^^1 

^^^^^^       Case  of   CcntrnI  Ohoroido-retinitie  (H<cui'ring  ultci- 

^^H 

^^^^^^L         Iiaboiir  and  PoEit-]>axt»m  Htf<morrh&ge,  ihown  by 

^^M 

.^^^^V            Dr.  H..  MAdTACOHTOX  JOKXS     . 

^H 

^^H^             UtrruB  removed  by  Porro's  Opfriitiun,  shown  by  Dr. 

^^H 

'^^H                      CorJ.TKOWOBTH               .... 

^H 

^^^1              Fuitua  uuil   PlucantA  from  a  Caee  of  Extra-uterine 

^^H 

^^H                  GeatatioD.  eliawD  by  Dr.  GoLLtNawoBTU 

135          ^H 

^^^1              Ouioeroua  Uteri  removeiS  by  ViLginuJ  Hystorectomy, 

^^H 

^^H                  Bbutrnby  Dr.  ODLLiMdvroBTE   . 

^H 

^^H               I>ifiea«ed   Ovaries  and   Tubes,  abown  by  Dr.  C.  H. 

^^H 

^^H                  Cabtek          ..... 

136          ^H 

^^^1              Thr^c  Specimens  of  Cot-vit  Ut^ri  removed  foi*  Molig- 

^^H 

^^^1                  nant  Diseasi^  ahown  by  Dr.  LEWERa 

^^M 

^^H             Cue  of  Ca&cor  of  upper  part  of  Cervix  extending 

^^H 

^^^f                  into  Body  of  tJterua.  shown  by  Dr.  Herman 

137           ^H 

^^H              Surcouatouit  Utems  removed  by  Vaginal  HyBt«reo- 

^^H 

^^^                   tomy,  Bbovm  by  Dr.  Dakin 

13»          ^H 

^               VI.  Four  C'aAett   of  Yagiuiil   Hyateiei^tuujy.    By  C.  J. 

^^H 

^^L                       OOLLIKOWOBTH,  M.D.,  F.R.C.P. 

141           ^H 

f        Ihy  7Ui.  1890- 

H 

L                       Ct«niB  abowing  the  effects  of  u  Guugrimoaa  Fibroid, 

^H 

1                          thown  by  Mr.  J.  Bhi.VD  Sotton 

^^M 

^^K              AxiB'prcHsnt^  Binder  fur  uae  during  Ltkboar,  aboira 

^^H 

^^M                 by  Dr.  Atma&d            .... 

^H 

^^V              Adjouraed  DebatL-  ou  Dr.CcLLiKOWQKTH'e  paper  on 

^^H 

^^^^^_           FoiU'  Caaos  of  Vaginal  Hyaturectotny 

174          ^H 

r       Jane  Itb,  1890— 

H 

■                      Glands  uf  tbo  Fullopiaa    Tube,   ahoim   by   Mr.  J, 

^H 

^^^                BtJkVJ*  Brjnov           .... 

^H 

^^H              ApopUu:lic  Oviiin.  shown  by  Dr.  Auakd  Rodth 

194          ^H 

^^^B               Dt«ra«  and  Adherent  Placenta  from  Puticut  dying  of 

^^H 

^^^^^_           Poat-pnrttim  UieiaorrbBge.  shovn   by  Dr.  Juhn 

^^1 

^^^^B         PuiLLipa       ..... 

^H 

^^^^^^       SpeciinenB   from   a  Case  of   Pnnilvnt  Seai1<^  EndO' 

^^H 

^^H                  Dtctritix.  shown  by  Dr.  Ub.buak 

^H 

^^H              Caretnoraa  of  the  Ovary,  ahowa  by  Dr.   Oullimo- 

^^H 

^^^^—^         KOBIR            ..... 

^H 

CONTENTS. 


PAGB 


Vli.  Siseeotion  of  u  Fcetue,  the  Babjaot  of  Betroficxion, 

Ectopia    yiacermn,    etc..  with    Remarks    on   the 

Frequent  Aesociation  of  tbeae  Abnorm&titieB,  and 

ita  CauBe.    By  W.  B.  Dakis,  M.D.  .    800 

Tni.  Case  of  Spnrioua  Pregniuit^y  simuUtiug  Sctopi«  Oot- 

tation.    By  E.  Sincljlie  Stevemsos  .    216 

rX.  Pevcr  in  ChiIiSlM>d.    Pui-t  I, — General  Hygieae  and 

AntisepsiB.     By  Eobeat  BoxAiii.,  M.D.  .  .    219 

July  3nd,  1890- 

Docidua  V«ra  and  Refleia  from  a  veiy  Early  Alwr. 
tii>a,  shown  hy  Dr.  HebhAH        .  .  ■     S72 

Foetus,  Plaeentn,  U^mbranca,  and  Fallopian  Tube, 
frotn  a  Caae  of  Ruptured  Tubal  GoatatioD.  com- 
plicated by  a  larg«  Has  ma  to- salpinx  on  the  oppo- 
utte  side,  shonn  by  Dr.  Cdllimqtcobtb    .  .    273 

Foroi-  in  Childbed.  Part  L — GGii«ral  Hygiene  and 
Antisepaia  {continued).    ByBoBEsr  Boxaxl,  U.D.    275 


October  2nd,  1890— 

Vole  of  Oondi^l«i]c«  on  the  deatb  of  Dr.  J.  Matthews 
Duncan  .....    S06 

Right  Ovary  and  Tube  distended  with  Blood,  sliown 
hy  I>r.  WniiAM  Dmoiu  .806 

nterine  Appendages  tlie  sabject  of  Tuberanlar 
Deposite,  eliown  by  Dr.  Williau  DrifCAN  .    SOS 

Uterus  with  Primary  Camcn-  of  the  Body,  estiifated 
per  vaijinain,  ahuwu  by  Dr.  Wuj.iam  Duncan        ,    306 

DelbaBlaillti'a.  Speculum  iV  glisgieree,  shuwn  by  Ur. 
Albas  Dobah  .307 

Tubal  gestation  removed  before  Rapture,  shown  by 
Dr,  Hbbmah  .....    307 

Pelvic  orgiinii  of  a  Pationt  dying  from  Injection  of 
Acid  Nitrate  of  Mei-cui'y  into  tlie  Tagina  to  pcudue* 
Abortion,  shown  by  Br.  John  Phililifs  .  .    308 

X.  Cas«  of  Symmetrical  ErjBipelas,  followed  by  Prema. 
turu  Labour;    SuIutupBia  on  the  niaetet-nth  day 
post-partum  ;  Twenty.^'jght  ParoiysniB;  no  Renal 
Disease ;  Recovery.     B;  JamiE80:4  B.  QuBRV,  Ai.D.     309 
XI.  Four  Casea  of  Pregnancy  with  Bright's  Disease.     By 

0.  Bbkebt  Hekman.  M.B.,  F.R.C.P.  .    880 


COBTEHW. 


Id 


PAOS 

NoromW  5th,  1890- 

Cm«  of  Tubal  Abortion,  Bhowo  hj  Mr,  J.  Bland 
Sutton  .  .342 

Suppm-ating  Dermoid  Ojat,  ahown  by  Dr.  William 
Duncan  .346 

Ovo-rf  and  Vuhe  ynth  Pupilloma,  shows,  hy  Dr. 
William  Ddmcan      ....    346 

Case  of  AcephiilouB  Acardiac  Twin,  shown  hj  Dr. 
AjJAND  ROCTH  ....     $47 

Fonr  Cues  ol  PreguHJicy  with  Brighl'e  Disease 
(canttnned).  By  G.  Eknest  HBBHAir,  M.B., 
FJt.C.P.  .  .349 

XH.  On  Plugging  Ihd  Uk^niB  in  Suvero  Ciisee  of  Post. 
partum  H^EUorrhage,  wtUi  Notoe  of  a  Successful 
Cue.    By  Arthur  H.  N.  Lbwbks,  M.D.  .    356 


December  3rd,  1890. 

Statement  by  the  Preaident  (Dr.  Galabin)  rcHpooting 
the  Action  of  the  Coaacil  with  re^rd  to  the  pro- 
posed Biil  for  the  Eegifltration  of  Midwivea 

Polypoid  Myoma  of  the  Uterus,  shown  hy  Dr.  AUST 
laWBSNCB     .  .  .  .  . 

Votical  OaJcnli,  shown  by  Dr.  AC8T  Lawbbkoe 

Ca«t  of  a  lai'ge  Vesical  Calculus,  shown  by  Dr.  Auet 
Lawbbncb    .  .  .  ,  , 

Calcut)  from  a  Case  wf  Prolapse  of  th«  Uterus  and 
Bladder,  shown  by  Dr.  Pekct  Bodltox  . 

Fcetua,  the  suhject  of  Atresia.  Ani  Veaicalis,  shown  by 
Dr.  Dakis     .... 

FapiUomatons  Uva,i-la.u  Cysts  romoTed  during  the 
fourth  moulb  of  Pregnancy,  abowu  by  Mr.  W.  A. 
UlBEDITH     .  .  .  .  . 

Sarcoma  of  the  TTterns  removed  by  Vaginal  Hjater- 
cctomy,  shown  by  Dr.  Gow 

Raptured  Uterus  oconrring  during  Labour  and  nfter 

External  Violenoe,  shown  by  Dr.  JOHH  PuiLLIi'S  . 

XXU.  Note  on   the  OpLTutiou  for  Keetonug  the  Perineal 

Body  in  Complete  Kupture  of  the  Pemalo  Perineum. 

By  A.  E.  AnsT  Lawrence,  M.D. 


365 

366 

366 

366 

367 

.    368 


374 


375 


377 


Ixii  CONTENTS. 

PAOB 

XIV.  The  Pm-se'Striiig  Satore ;  its  TTee  in  Complete 
Ruptnre  of  the  Ferinenm.  By  Febox  BoxjLTOir, 
H.D.  .380 

XV.  Habitual  Abortion.    By  A.  D.  Lbith  Napibk,  M.D.    389 

Index  .  .  .  .409 

Additions  to  the  Libbabt      ....    427 


PLATE. 

Apoplexy  of  tita  Ovar;,  OjKtic  ]>itfttalioii  without  Rupture 
{Mr.  Albas  Doban) 

The  Bight  Ovary  with  ite  Interior  czpoeed  by  Section 


PAOI 


WOODOCTS. 

Five  Cfwes  of  Faerporol  Eclampsia,  eepocioUy  illustratitig  (be 
Teraperature  and  Crine  in  this  Disease  (Or.  HbbuanJ 
Cuw  I.       Chart  1 
Cmo  II.      GhATt  1 
Case  II.      Chart  2 
Ca««  lU.    Chart  I 
CMC  III.    Chnrt2 
Ca«e  V.      Chart  I 
tTrctiml  Diverticuln  CDr.  Ahabd  Roitth) 
Ut«m«  showiufi  tho  Effects  of  a  Gangrenous  Pibroid  {Mr.  J. 
Blasd  SorroN) 

Pig.  I . — Bection  of  UleroS  from  which  a  Oongrctioua 

Fibroid  biul  bucs  removed 
Fig.  2. — Abdoniiaal  Ostium  of  the  Tabe 
GlAnda  of  the  Fallopian  Tube  (Mr.  J.  Blasd  Sottok) 

Pig.  1. — TraiiBvcrae  Section  through  the  Fallopioji 
Tube  of  it  Mnca<]Uii<  Mouley,  Ifaatcttt  rhtttia,  to 
ehow  the  gland-cluatcra 
Fig.  2. — A  Compound  Racemoat!  Gland  from  the  Fal- 
lopian Tube  of  thu  PanoHan  Seer,  Cervut  etdi 
Fig.  3.— Microaeopicnl  Characters  ot  a  Fallopian 
Adenoma  (Doran'e  cose),  for  oompariaon   with 

Pig-1 

DiEsection  of  a  Fostus,  tho  subject  of  Betroflezion,  Ectopia 
Viscemoi,  &6.  (Dr.  Daxin) 

Fig.  1. — Sbotriag  Heart,  Liver,  8ac  contaiQing  Kid- 
ney, Ac,  and  Intestinoe  with  Diat«adcd  Colon 
Fig.  2.^^bfiiii«  ot  Aortic  Braiich«ji 


190 


191 


198 


202 


Ixiv 


WOODCHTS. 


PAOK 


Tig.  3. — Showing  arrangQineiit  of  Lamins  aad  Bibe, 
&pmB.  Bifida,  approsimatioii  of  Eachial  TnbCTori- 
ties,  and  Flexion  of  Spine 

Tig.  4-. — Showing  shape  of  Thdraje,  Plerion  of  Spine, 
Everaion  of  Ilia,  and  position  of  Coccyx 

Fig.  5.— Attitude  of  Fffitns  in  ntero 
Fever  in  Childbed.     Part  I. — Cfeneral  Hygiene  and  AatiaepBis 
(Dr.  BOXAIL) 

Chart  I  ....  . 

Chart  JI  .  .  .  .  . 

Chart  m  .  .  .  .  . 

Four  Caaea  of  Pregnancy  with  Bright's  I}ie.eaB«  (Dr.  HsBUAir) 

Caae  I.        Chart  1  .  .  .  . 

Oa.se  II.      Charba  ,  .  .  , 

Case  ni.     Chart  3  .  .  .  . 

Ofise  of  Tuba!  Abortion  (Mr.  J.  Bland  Sutton) 

Fi(f.  1 . — Ovarian  Cyat  of  th«  right  side,  with  an  Accqb- 
8ory  Ostinm  to  the  Tube 

Fig.  2.— The  Left  Tube  op«n6d  to  expo&e  the  Apo- 
pi  actio  Ovum  .... 

Fig,  3. — The  Ovum  in  gitu  .  .  . 

Fffitan,  the  subject  of  Atresia  Ani  TeeicaliB  (ttr.  Dakis) 

Fig.  1. — Showing  AbdominaJ  Protuberaiice,  Beformi- 
tieB  of  Legs  and  Feet,  and  Spina  Bifida 

Fig.  ".—Cyst  tallied  do^vn,  ehowing  large  Intes- 
tine, &c.      ..... 

Fig.  3.— Cyat  opened,  showing  Pn^atatic  Cavity,  &c. 

FigB.  4  and  4a. — Showing  Mode  of  Origin  uf  Abnor- 
mality ..... 
The  Pni-se-string  Suture  j  its  Use  in  Compltte  Rapture  of  the 
Perineum  (Dr.  Pebcy  Bottltok) 

Fig.  1. — Complete  Riipturo 

Fig,  2. — Inciaions  neceeanry  for  Restoration 

Fig.  3. — Rectal  Tear  atit^liodi  Pui-se-stringSiittiro  in 
place  ..... 

Fig.  4. — Puree-string  tied;  Perineal  Sutnreintroduucd 


209 

208 
209 


235o 
23tfe 
23Sc 


343 


369 


373 


383 
383 

.389 
385 


ADYHBTISBMENT. 

Thb  Socibtt  ie  not  as  a  body  Tesponsible  for  the  focta  and 
opinions  which  are  advanced  in  tbe  following  papers  and  com- 
nmnioationB  read,  nor  for  those  contained  in  tbe  abstracts  of  the 
disoasttona  which  hare   occurred   at    the    meetings    daring    the 


20,  HxHOTSB  Squabs,  W. 


LIBRABT  AND  MUSEUM, 
20,  Hamoteb  Sqdabb,  W. 


Honrs  of  Attendance:  Monday  to  Friday,  1-30  p.m.  to  6  p.m., 
Saturday,  9  a.m.  to  11  a.m.,  and  in  the  Eroiings  on  which  the  Society 
meets,  &om  7.15  p.ni.  to  7.46  p.ni. 

R.  W.  8ATAGB, 

Zi&rorMta. 


TOIi.  XXXII. 


OBSTETRICAL     SOCIETY 


o* 


LONDON. 


SESSION  isrto. 


JANUARY  8rn.  1890. 

A.  L.  Gaiabim,  M.D.,  Presidentj  in  the  Chair. 

PraiwDl— 28  Fellowa  and  2  Viaitors. 

Books  were  presented  by  Dr.  Auvard  tad  Dr.  Godson. 

James  Oliver,  M.D.,  P.E.S.Edin.,  was  admitted  a 
Fellow  of  tKe  Society. 

Harry  Marmaduko  Pago,  F.R.C.S.  (Oxford),  and 
Arthur  Hardwick,  M.D.Dubl.  (Newquay),  were  declarud 
admitted. 

The  following  gentlemen  wore  clocted  Fellows  of  the 
Society  : — Robert  James  Carter,  M.B.Lond. ;  Charles 
Plumley  Child©,  L.R.C.P.LoDd.  (South&oa)  ;  Edward 
Henry  Douty,  M.A.,  M.B.,  B.C.Oantab.  (Cambridge)  ; 
Harry  St.  Clair  Gray,  M.D.,  C.M.GIaB.  (Glasgow)  ;  T. 
Arthur  Heline,  M.D.Edin.  (Manchester)  ;  Charles  Henry 
JamcB,  L.R.C.P.Lond.;  Ernest  E.  Lewis,  L.R.C.P.Lt)nd.  j 
Cbicheator    Gould    May,    M.A.,    M.B.Cantab.    (Doblin)  ; 

VOL.  XXXIl.  1 


2      BAFIDLT    FATAL  CSBSBRJU.  SSUO^&EAQ^  IN  A  CASE   OF 

Godfiey  Forrest  Reid,  M.D.Dubl.  (Orange  Free  State)  ; 
Jolin  Frederick  William  Silk,  M.D.Lond. ;  Charles  Her- 
bert Thompson,  B.A.J  M.D.Dubi. ;  and  Ckarles  Porcival 
White,  M.E.C.S. 

The  followiog  genlleinen  were  proposeil  for  election  : — 
Chrifttoplier  Martin,  M.B.,  CM.  (Middlesbroagk)  ;  Ben- 
jamin Wilfred  Thomas,  L.B.C.F.Load.  (Welvrjo)  ;  and 
George  Porter  Wornom,  M.B.C.S. 


RAPIDLY  FATAL  CEREBRAL  HJEMORBHAGE 
OCCUERING  IN  A  CASE  OF  PREGNANCY 
COMPLICATED  WITH  MULTIPLE  FIBEOIDS. 

By  WiLUAM  DoHCiN,  M.D. 

Db.  WrLLrAB  DdNcah  showed  the  TiternB  and  kidneys  of 
this  patient. 

Mrs,  S — ,  aged  42,  was  admitted  into  the  Middlesex 
Hospital  &n  October  25tli,  1889,  complaining  of  swelling 
of  the  abdomen.  The  catamecia  began  at  twolvo  years 
of  age.  They  Lad  always  been  regular  and  lasting 
three  daygj  and  never  were  profuse.  The  patient  bad  one 
child  £.76  years  ago ;  no  miscarriiirgeB.  Tlie  last  period 
ceaeed  on  Sana  10th.  In  Angust  a  email  swelling  waa  first 
noticed  in  the  lower  abdomen,  which  for  six  weeks  before 
admission  rapidly  increased  in  ei^e. 

State  on  admissioTi, — A  florid-complesioned,  spare 
woman. 

Breasts  enlarged,  with  dilated  veins  coarsing  over 
them,  nipples  prominent  and  areolae  darkened ;  thick 
creamy  Becretton  could  be  squeezed  from  both. 

Abdomen  diatonded  by  central  tumoar  o£  elastic  nafcare, 
reaching  an  inch  above  the  umbilicus.      Surface  covered 


PBEOKANCT   COKFUOATID  WITH   IICLTIPLB   FIBS0IO8. 


with  namerous  hard  tnmoara  varyiiig  in  aiso  from  u  ^mall 
orange  to  a  marble.  Intermittent  uterine  coutractiona, 
nterine  Bonffle,  and  fcctal  heart  all  made  oat. 

Ptr  vaginam. — Mucous  membrane  port-wino  colour, 
Os  oteri  looted  downwarclB  and  backwards.  Cervix  en- 
larged^ swollen,  and  soft.  The  cervical  canal  easily 
admitted  two  Bngcrs.      No  balEottement. 

Urine  acid,  ep,  gr.  1030,  trace  of  albumen. 

The  patient  was  kept  in  hospital  for  cliuicol  purposee 
for  three  weeks,  during  which  time  fresh  tamours  were 
detected.     Discharged  from  hospital  !Norcrabor  15th. 

Readmitted  on  December  25th  (Christmas  Day),  at 
12.30  p.m.,  in  a  restleBi?  and  comatose  condition. 

The  following  history  was  elicited  from  a  friend  ;— 
"  Since  leaving  the  hospital  patient  had  been  in  very  fair 
health  and  able  to  do  her  house-work  daily ;  at  nu  time 
had  ehe  had  any  fita  or  conyalsiuua.  On  Christmas 
ntoming  she  got  up  at  8.30  a.m.,  feeling  perfectly  well, 
and  continued  eo  until  10.30  a.m.,  when  she  complained 
of  sudden  acute  headache.  At  II  a.m.  she  was  found 
totally  unconscious,  toeeing  her  armu  about  (especially  the 
right),  and  breathing  deeply  and  heavily.  She  was 
brought  to  the  LoHpital  iu  a  cab. 

8tat«  on  admission.— Deep\y  comatose,  but  throwing 
arms  and  legs  about,  and  moving  the  whole  body ;  move- 
ments moro  marked  on  the  right  side.  Breathing  deep, 
lend,  and  noisy.  Bespirations  40.  Pulse  hard,  of  small 
Tolomef  110.  No  rolaration  of  sphincters.  The  eyes, 
&oe,  and  head  were  turned  to  the  left. 

Catheter  pasued,  and  ^ss  of  nrine  loaded  with  albumen 
drawn  o0. 

Dr.  Duncan  was  at  once  sent  for,  but  being  absent  from 
town.  Dr.  Boxall  arrived  at  1  p.m. 

The  patient  was  now  more  deeply  comafcoae  ;  respira- 
tiomi  -48,  and  there  was  total  paralysis  of  arms,  legs, 
face,  &o.     The  temperature  was  not  taken. 

The  face  waa  of  a  parple  hue,  and  so  venesection  was 
performed,  five  ounces  o£  dark  blood  being  removed,  iol- 


4  fI/FIT)I.T    FATAL    CKXKHRAL    HJCXO&RRAOB. 

lowed  by  sliglit  improvement,  which  was  only  oE  short 
duration.  It  was  tlieu  decided  to  empty  tlie  aterua.  The 
cervix  was  easily  and  rapidly  dilated  by  meana  of  the 
hydrofllfttic  bag-s,  and  version  performed,  but  deabh  resnitod 
before  the  delivery  could  be  completed. 

Pont-morUm  examination. — Subject  fairly  well  uouriahed. 
Ccnsiiiflrable  poBt-mortem  stainiug.  On  bend  of  ngbt 
elbow  was  a  venesection-wound  closed  by  recsent  lymph; 
the  vein  (median  basilic]  was  filled  by  a  clot. 

On  opening  tlie  abdomen  a  few  ounces  of  clear  BerooB 
fluid  escaped.  The  uterus  (contuining  many  firm  sub- 
serous, aod  interstitial  fibroids  averaging  an  Inch  in  dia- 
meter) was  found  adjacent  to  the  abdominal  wcitl  and 
reaching  to  within  a  finger's  brcftdth  of  the  umbilicus. 
Th0  organ  with  the  vagina,  and  appendages  was  removed 
and  laid  open  from  behind ;  tho  incision  showod  the 
uterus  to  be  partially  contracted.  The  placenta  and  mem- 
branes of  a  fcetus  of  less  tliau  full  time  occupied  its  cavity, 
tho  former  beiu^  situated  at  the  left  angle  and  poBteriorly, 
BO  that  a  small  frag-miMit  of  It  v/aa  cut  off  by  the  inoiaion  ; 
tho  placenta  scorned  to*bo  placed  oror  tho  orifice  of  the 
loft  Fn.llopinu  tube. 

Ovnrien  and  tubeM  were  normal. 

Brnin. — Considerable  venoas  congestion  was  noticed  on 
removing  altalUcap.  On  removing  brain  a  very  exteneive 
hsmorrbage  was  fouud,  seemingly  into  the  subarachnoid 
spftce,  which  extended  over  the  wtolo  baso  of  the  brain^ 
a.nd  upwards,  laterally,  to  the  temporo-splicnuidal  lobe?. 

On  incising  the  brain  a  very  extensive  heemorrhage  was 
discovered,  apparently  into  tie  snbstance  of  the  island  of 
Beil  on  the  right  side ;  it  penetrated  deeply  into  the 
Ifttern-l  and  fourth  ventricles. 

About  five  oaocesof  blood  had  escaped  from  tho  vessels. 

Heart. — Tricuspid  valvfs  tliick  and  slightly  puckered  ; 
apparently  competent.  Mitral  valves  much  thickened  ;  on 
one  was  a  smalt  vegetation  with  loosely  attached  thread  of 
fibrin  ;   valve  seemingly  competent. 

Left  kidney. — Capsule  very  adhoroot  to  kidney  and  to. 


kC'HCHMKTKb'h   TBAWariraiON   APPAKATtrS. 

sutTOuncliug  connective  tiasue.      Surface  of  organ  puckered 
and  covered  with  multitudiuoas  cjats.      Cortical  eubBtance 
greatly  wasted.      Many  more  cysts  seen  within  the  kidney 
on  section.      Medullary  substance  normal. 
Alt  other  organs  normal. 


mUnchmeybr*s  transfusion  apparatus. 


By  J.  Matthews  Ddncan,  M.D. 

Dr.  Mattukws  Duncas  exhibited  Miincliioeyer'n  instru- 
meot  for  trauBfusion  in  cases  of  nearly  fatal  haMtiorrbiige, 
aooordiDg  to  a  plan  of  his  and  Leopold's  ('  Archiv  {ur 
Gynakologie,'  vol.  xxxiv,  pt.  3,  p.  38).  By  this  a  \iy^<i- 
dermic  injection  of  sterili«od  water  at  blood  heat,  and  bear- 
ing in  solution  chloride  of  sodium  (a  drachm  to  a  pint),  was 
made  to  the  extent  of  one,  two,  or  three  pints.  The  effects 
were  said  to  be  as  good  as  when  the  fluid  was  injected 
into  the  »eins.  He  had  long  recommended  watery  injec 
iion  directly  into  the  veins  by  a  common  syringe  ;  but 
this  method  of  Miiuchmeyer's  was  simpler  and  less  daoger- 
oaa.  The  injected  water  had  to  be  diffneed  by  manipula- 
tion, and  it  was  rapidly  absorbed.  Traniifufiion  uf  ordinary 
kinds  had  excited  and  maiutaiuod  great  enthu^iatim  in  the 
profession,  but  its  uae  was  unsatisfactory  and  very  danger- 
ous. It  had  never  come  into  practice  as  an  established 
resoarce  ;  and  no  wonder,  for  a  lute  systematic  writer,  while 
recommending  it,  said  it  killed  more  than  it  cured. 
Science  bad  done  much  to  explain  the  bad  results  that 
frequently  followed  it;  and  scieuce  indicated,  water  to  fill 
the  void  cauwd  by  hiemorrhage  to  be  the  best  Snid  to 
nse — the  Bafest.  He  hoped  that  Miinchuieyer's  method 
of  sabcutaneouB  injection  would  prove  a  useful  and  bandy 
rosoarce  in  the  terrible  post-partura  haimorrhages.  Munch- 
meyer  and  Leopold  injected  into  the  loose  cellular  tissue 
near  the  s<»putB. 


OTARIAN  CYST,  PARTLY  DBBMOID. 
By  C.  H.  Cabtir,  M.D. 


TWO   DERMOID    CYSTS    FROM   THE    SAME 
PATIENT. 

By  C.  H.  CiETBE,  M.D. 


LIPOMA    REMOVED    FROM    LEFT    LABITJM 
MAJUS  OF  A  WOMAN  AGED  FORTY. 

By  0.  H.  Caetkb,  M.D. 


SHOULD    PREGNANCY    BE    TERMINATED    PRE- 
MATURELY IN  CASES  OF  PHTHISIS  P 

By  William  Doncah,  M.D., 

OBSTBTBIC  VSTBJtiUX  TO  VOX  UBIlLiteHX   HOBFITAJi. 


(Rwrived  0«tobor  SSnd,  1S890 


This 


was  a  queetioD  I  had  to  consider  lately  when  asked 
by  my  friend  Dr.  T.  Cranstonn  CharloB  to  indace  abortion 
for  a  medical  man's  wife  the  subject  of  advanced  pbtliisis. 

Tlie  history  of  the  cose  is  aa  follows : — Mrs.  B — ,  aged  27, 
was  married  tour  jearB  ago  and  has  had  two  children,  the 
firflt  being  bom  ten  months  after  marriage ;  the  seconti, 
eixteen  months  after  the  first.  The  catamenia  commenced 
when  sho  was  thirteen,  and  were  always  irregular,  there 
often  being  amenoprhcea  for  tbree  or  four  months.  Both 
ber  confinements  were  prolonged  and  difficult,  owing  to  the 
lai^  size  of  the  children's  heads :  the  first  lasted  thirty- 
gir  hours,  and  the  second  twenty«five.  Chloroform  was 
given  for  many  hours,  bat  the  forceps  was  not  used.  The 
placenta  of  the  second  child  had  to  be  removed  piecemeal. 
There  was  an  absence  of  milk  in  the  breasts  after  both 
labours. 

Family  hitiory. — Oae  maternal  ancle  died  of  pbthisis  ; 
all  other  relatives  healthy. 

Chett  history. — Had  double  pleurisy  resulting  in  pleuritic 
adhesions  seven  year»  ago. 

Fouryeam  ago  (afew  months  before  marriage)  there  was 
congh  with  slight  crepitation  at  the  left  apex  ;  the  physical 
signs  increased  during  the  ensuing  pregnancy,  and  after 
the  birth  of  the  child  there  was  a  decided  chango  for  the 


8 


FBXaNAHCT   IK   CASES   Of   PUTDTSIS. 


worse  :  the  expectoration  was  more  profnee  ;  the  rdle»  wero 
mush  louder,  and  -covered  a  large  urea  of  the  left  lung, 
the  right  lung  remaining  sound. 

After  the  second  conBnement  she  was  laid  up  iu  bed 
for  nearly  three  ruonths,  the  lung  aig-as  getting  gradually 
and  steadily  worse. 

Aboub  two  years  ago  she  waa  seea  by  Dr.  Quaia,  who 
urged  the  aece&sity  of  no  further  pregnancy  taking  place. 

Pour  monthly  ago  a  cavity  wfis  detected  beneath  the 
middle  o£  the  loft  oltivicle  ;  the  lower  baU  of  the  left 
lung  and  the  npper  part  of  the  right,  near  the  stermim, 
showed  crepitation.  At  no  time  bad  there  been  much 
blood  in  the  sputum,  but  occaaionally  a  small  clot  had  been 
expectoriited. 

Id  August  last,  as  she  had  missed  two  perioda,  and  be- 
lieving herself  pregnant,  she  came  up  from  Worcestersbir© 
to  consult  Dr.  Quain  again ;  in  his  absence  she  wae  exa- 
mined by  Dr.  Allchiu,  who  gave  it  as  his  opinion  "  that 
her  life  would  he  shortened  if  the  pregnancy  were  allowed 
to  go  on." 

Taking  all  the  conditiooB  present  into  conBideratJoD,  I 
agreed  with  the  opinion  above  esprot^ficd,  and  consented  to 
empty  the  uterus;  this  I  did  as  follows  on  September  Hth. 
Dr.  CTanBtoim  Charles  and  Dr.  B —  (the  husband)  wero 
present.      Dp.  F^rederiek  Hewitt  gave  t-hioroform. 

The  patient  was  placed  in  the  lithotomy  position,  the 
TuIIva  and  vagina  well  washed  with  a  1  in  2000  solution 
of  mercuric  chloride  ;  Sinis's  speculum  introduced  and 
the  cervix  firmly  seiaed  by  a  rolsella.  Next,  the  cervical 
cuiinl  was  easily  and  rapidly  dilated  with  Begar's  dilators 
Up  to  Xo.  22,  when  the  finger  was  inaertod  and  the 
foetus  and  raembranea  removed ;  then  the  whole  uterine 
macous  membrane 'was  carefully  curetted  to  remove  all 
the  decidua),  the  cavity  irrigated  with  a  hot  mercurial 
douche,  and  lastly  a  twenty-grain  iodoform  bougie  was  in- 
troduced into  the  uterua  and  retained  there  by  a  glycerine 
plug  passed  up  to  the  oa  uteri.  The  operation  lasted 
twentv-Sve  minutes. 


riBOKA^iCS   IN    CASES   OF   PQT016I3. 


0 


Tbo  subsequent  progress  was  in  every  res pect  satisfnoiory, 
tlicro  was  absolutely  no  pain  whatever,  ito  rise  of  teaipera- 
tnrfr  or  piilao ;  there  was  a  very  ^ligbt  sanious  discLa.rge 
for  two  days,  after  which  there  was  none  of  any  kiud. 
The  patitiut  returned  home  exactly  three  weeks  after  the 
operation. 

Rtrmarht. — It  seems  to  me  that  this  subject  requirea 
careful  cuuKidcratiuu  and  discsussion,  for  in  not  a  siugle 
text-book  on  obstetrics  that  I  have  consulted  can  I  find 
any  montion  of  the  induction  of  abortion  or  of  premature 
labour  id  oases  of  phtliisis. 

It  is  now  a  wcU-Tocogniscd  fact  that  when  a  phthisical 
woixiaQ  conooivca,  tho  progress  of  the  digoEiee  (inatoad  of 
being  retarded  as  old  authoritiGH  held)  is  ImHteued  ;  tbiH  is 
especially  the  case  in  young  women  "between  twenty  aud 
thirty  years  of  age.  I  have  seen  several  instances  of  it, 
aud  the  case  just  recorded  hears  out  the  view. 

Let  us  first  consider  early  pre^^Tiancy  in  a  phthiuical 
woinan,  luid  then  pregnancy  when  the  child  has  bBCOiue 
Tiable, 

Now,  ia  the  case  of  early  pregnancy  in  a  woman  the 
subject  of  well-marked  and  progressive  phthisis,  I  think 
there  can  be  no  question  that  the  proper  courae  to 
pursue  is  (alter  carefully  considering  the  case  in  consulta- 
tion) to  tmpty  the  uterus  of  its  contents.  And  if  this  be 
done-  in  the  manner  just  described,  taking  every  possible 
prccantion  against  the  occurrence  of  sepsis,  there  need  be 
_iio  fear  of  any  ill  effect  ensuing. 

But  I  will  go  furtlicr,  and  maintain  that  the  same  coorso 
should  bs  adopted  in  a  similar  case,  but  where  tlie  phthisis 
is  stationary  ;  for  when  we  consider  that  the  disease  may 
be  lit  into  activity  during  any  period  of  pregnancy,  that 
as  a  result  of  the  expenditure  of  vital  force  consequent  on 
the  process  of  labour  at  term,  and  tho  degenerative  changes 
taking  place  during  the  puerperium,  logotber  with  tho  fact 
that  the  woman's  offspring  will  ino^t  likely  be  puoy  and 
weak,  and  probably  die  within  a  few  months  after  birth, 
the  advantages  to  the  woman  of  having  the  uterus  at  once 


10 


rBSOKAHOY    IS   CASKS  OF  PBTBISIS. 


»nd  completely  emptied  far  outweigb  the  adTantage  of 
goiag  on  to  term  for  ttie  sake  of  a  Kriag  child,  oapecially 
fts  dcliTery  nt  term  is  almost  certain  to  bo  followed  by  a 
more  or  less  rapid  downhill  progress. 

When,  however,  we  oome  to  consider  tho  case  of  a 
phthisical  woman  seen  for  the  Q.rst  time  when  the  child  i» 
viable,  the  question  ariaea  in  one's  mind  whether  the  better 
course  to  adopt  would  be  to  let  the  pregnancy  and  labour 
tennimLte  naturally  or  to  iodnoe  labour  prematurely. 
PofBOnally,  I  ahonld  feel  disposed  In  a  case  of  this  kind 
to  be  guided  in  my  treatment  by  the  Inng-condition. 

If  the  phthiaia  at  this  advanoed  period  of  pregnancy 
were  quite  stationary  (thongh  well  marked)  I  should  wait 
nntil  full  term  had  nearly  arrived,  and  then,  in  order  to 
save  the  patient  all  suffering  and  the  strain  on  her  system 
congcquent  on  natural  delivery,  I  shoald  have  her  auses- 
thetiaedr  and  (whilst  carrying  out  every  anfciseptio  pre- 
caution) then  dilate  the  cervix,  first  using  graduated 
bongii>s  (such  as  Hegar's),  followed  by  the  hydrostatic 
dilators  until  the  eerrix  was  sufficiently  expanded  to 
permit  of  delivery  by  the  forceps  or  version  as  the  case 
indicated,  performing  what  may  be  termed  "accouche- 
ment rapide "  as  distinguished  from  "  aocoucbement 
forc^." 

If,  however,  the  phthiaia  were  markedly  advancing,  (t 
seema  to  me  that  the  interesta  of  the  mother  and  child 
would  be  best  served  by  effecting  delivery  in  the  above- 
mentioned  mann&r  without  delay,  not  waiting  until  the 
full  term  had  been  reached. 


Dr.  CrLLiirowoBTH  apologisBd  for  intervening  betTeen  ihe 
paper  and  tlie  diecueeioD,  He  thought  it,  however,  due  to  the 
Fellowa  to  place  them  in  poasesBiou  of  a  i'ew  fLddltional  facta  in 
reference  to  the  case  before  them.  The  patient  iiiiquoaliou  (who 
was  the  wife  of  a  medical  man)  bad  been  originally  eeat  to  him 
with  &  note  from  Dr.  T.  CracBtoun  Charles,  stating  that  the  case 
wna  one  of  pulmonary  phthiaia  with  pregnancy,  and  that  it  wai 
seceBsary  that  abortion  should  be  inducod,  and  asking  him  (Dr. 
Cullingrrorth),  in  caee  be  agreed  with  i>i.  Chulee'a  opinitfa.  to 


PBSOVA.KCT   IN  CASES  Of   PHTHISIS. 


11 


firrangementi  for  perfortniDg  the  operation  ftn  eoon  as 
ble.  Aft^r  se«iDg  tne  pati&nt  he  sotiglit  and  obtained  an 
interview  with  Dr.  Charlea.  That  ptyaician  then  expressed  hia 
belief  that  the  miBchief  in  the  lung  would  certainly  increaee  if  the 
pregnancy  were  allowed  to  go  on,  and  that  if,  on  the  other  hand, 
the  pregnancy  were  terminated,  the  patient,  notwithBtanding 
that  flbcj  had  a  cayity  in  the  !img,  could  he  cured,  It  further 
tranBfiLretl  that  Dr.  Charles  had  nbeolute  faith  in  the  efScacy 
of  a  new  treatment   that  had   hoen  proposed    for  the  cure  of 

Salmoniry  tuhercutoeis,  namely,  the  innalation  of  heated  air, 
[e  pointed  out  to  Dr.  Charles  that  the  posRibility  of  cure  in 
such  a  caae  was  a  matter  of  opinion,  and  that,  if  an  operutioD 
were  performed,  the  reiponaibility  would  rest  with  the  operator. 
He  aUo  reminded  Dr.  Clmrles  that  it  waa  by  no  meana  an  eetab- 
lished  fact  that  the  chances  of  life  in  a  coniiumptive  patient 
were  improved  by  the  indaetion  of  abortion,  which  was  a  moat 
Berioua  thing  to  do  under  any  circumetancee,  and  particularly 
HO  here,  for  he  waa  not  aware  of  the  operation  having  ever 
been  undertaken  on  mmilar  groundB.  He  regretted  that  ho 
could  not  accept  Dr.  Charles's  views,  or  acquiesce  in  the  opera- 
tive trfntiiicut  lie  propoaed,  lie  liaduo  alternative,  therefore,  hut 
to  decline  to  undertake  it.  Ue  had  heard  no  more  of  the  cane 
nntil  that  evening.  He  was  very  glad  Dr.  W.  Duncan  had 
brought  the  lubjcct  before  the  Society. 

Dr.  Hebkak  asked  upon  what  gronnde  did  Dr.  W.  Duncan 
ba»e  hia  opinion  that  the  existence  of  pregnancy  hastened  a  fatal 
tcrcoiaatiou  in  cases  of  phthisis.  lie  (Dr.  Herman]  waa  inclined 
to  the  same  opinion,  but  his  opinion  was  only  baat'd  on  vogue 
imprewions  derired  from  his  own  experience  ;  he  could  not  adduce 
any  evidence  Id  support  of  it,  nor  could  he  refer  any  one  who  held 
a  contrary  opinion  to  any  convincing  collection  of  cases.  If  Dr. 
Duncan  could  produce  or  quote  some  scientific  evidence  showing 
the  effect  of  pregunncy  on  phthiHia,  be  would  do  a  groat  service. 
If  Dr.  Duncan's  view  were  clearly  proved,  ho  (Dr.  Herman) 
thought  the  induction  of  abortion  wouid  be  proper  treatnieut. 

Dr.  PLJ.TFAin  aaid  that  while  he  must  admit  the  interest  and 
novelty  of  Dr.  William  Dnncao'a  suggestion,  he  could  hardly 
believe  that  it  was  one  i^-hich  either  would  be  or  ought  to  be  gene- 
nUy  acted  on.  He  presumed  that  Dr.  Duucan  did  not  intend  to 
noominend  the  induction  of  abortion  in  incipient  stages  of 
pbtbieis,  for  such  a  course  would  lead  to  the  greatest  poeeihlo 
abuse.  Dr.  Duncvi  had  eafegunrded  against  bia  own  action  bjr 
Tery  properly  having  a  preliminary  coDsultation,  and  subttcquentlr 
by  submitting  it  openly  to  the  criticism  of  the  Society.  It 
must  be  obvious,  however,  that  there  might  be  many  who  would 
trust  to  such  a  course  without  much  precaution,  and  who  would 
Bfaelter  themselvce  under  the  authority  of  Dr.  W.  Duncan's 
name.    In  MlTtDced  caaca  the  quostioo  was  different.    It  seemed 


12 


PBKONANCV    IN    CASES   DP    PHTHISIS, 


to  htm,  however,  thai  there  vaa  na  eitfltoreiit  groiiitd  fur  con- 
clmjing  that  puttiug  an  end  to  iter  labour  would  lualormllv  vheclE 
or  alter  the  progress  of  the  disease.  Mor«(>vor,  it  was  o  t^pj 
upea  (juestiou  whctlier,  iiudcr  eudi  cirvumstativuB,  tliu  mnthor 
betu^  nlreaJy  the  suhj^-ct  of  JulvmiceJ  urijauic  diHt^aHe.  the 
iuterei^ts  uf  ttie  child  should  not  be  tuktiii  iiili>  cuDHidemtiun.  On 
the  whole,  therefoK,  while  he  tiiinutt^d  the  force  of  aomv  of  Dr. 
DuacaQ'fl  argitmoutN,  he  believed  hia  case  waa  a.  dangerous  pre- 
cedent, and  thflt  the  cuurae  adupted  bj  hica  would  tiot  be  gener- 
fttly  approved  or  fallowed- 

I)r.  PuiEStLEZ  said  that  on  oae  poiat  thoj  would  all  probably 
be  agreed,  viz.  that  no  collateral  coDsidcratiou  ^uirli  &a  those  which 
had  been  alluded  to  by  Dr.  Cullingwortli  sliould  be  allowed  to 
influettce  pr^ctitiouers  io  determiniog  whether  it  wa«  right  t« 
induce  abortion.  In  a  paper  road  before  the  Society  »»iiie  yean 
ago,  "  Ou  the  Iiiductinti  of  Abortion  a*  a  Tliei-a|.ieutieMfaaure*' 
(vol.  xzii,  1880),  he  had  laiil  it  down  as  a  rule,  to  which  there 
were  practically  few  exceptions,  that  abortiou  was  only  a 
legitimate  Dperation  when  the  life  of  the  tnuther  was  ao  imperilled 
by  the  eonCinuanco  of  pregnancy  that  emptying  the  uterus 
preat^Dted  itaelf  as  the  ouly  alternativo  to  save  the  patient.  Not 
having  seen  the  case  in  which  Dr.  Wiiliam  Duncan  had  pro- 
voked ahortiou  because  ihe  woman  wbh  Buffering  from  plithitiia, 
he  could  not  eipresa  au  opinion  whether  or  no  the  measure  had 
beeu  imperatively  called  lor  hy  the  urgency  uf  the  symptomB; 
but  judging  Irom  esperience  in  such  t-iiees.  it  was  diiEcult  to 
conceive  iiny  eirt^umplaucea  in  whiuh  pljlliisis,  without  Botne 
other  eompHcfttiun,  would  justify  the  proi^eeding.  It  was  well 
known  that  phthiaionl  patients  had  a,  fertility  which  wao  aluioat 
abnormal,  aiid  he  believed  it  M-as  the  celebrated  Culteu,  of 
Edinburgh,  who  Srat  a»i^erted  that  phthiiiig  in  these  patients 
tieemed  to  be  suspended  or  retarded  by  the  cliances  going  on  in 
the  gravid  uterus.  A  wbole  string  of  autborn  had  testified  to 
the  itame  fact ;  but  only  recently  a  M.  Gaulard,  in  France,  hnd 
endeavoured  to  controvert  this  asaertinn,  and  he  averred  that 
there  wua  do  pause  in  the  pro^re?a  uf  tubercular  dimeuKe  in  the 
luDga  duritig  pregnaoey,  any  mure  than  in  other  dieeasee  of  the 
luugs  duriijg  thnt  condition.  But,  even  if  tbie  questiou  were 
better  determined,  one  anturally  asked  what  was  to  be  gained 
by  the  induction  of  abortion  in  phtlumcal  patients.  One  could 
not  pretend  that  it  would  conduce  to  the  cure  of  the  patient, 
aud  it  was  very  doubtful  if  the  operation  would  place  her  iu  a 
hetter  poititiou  alter  it  wan  completed,  liatlier  one  would  fear 
thai  the  irritation  provoked  by  it,  wheu  brouglit  on  by  auch 
A  method  aa  had  been  described  iu  this  case,  or  indeed  by  any 
other  method,  would  still  further  impair  the  etruogth  of  the 
patient,  and  put  her  iu  a  worse  position  than  if  allowed  to  f(0  to 
the  full  time.    Aa  at  proBent  intormod,  therefore,  he  should  not 


rscaMAiccv  i»  c&siib  op  fbthisis. 


18 


be  diqiowd  to  mqcUod  abortion   in   patients  sulFenDg  froia 
phtfafiritpulmnnalis  as  a  general  tlierapeutic  rue&:<uro. 

Dr.  CHAMipNKrB  raid  that,  liko  l>r.  llertimOj  he  Eulij  eipected 
th»t,  in  Unnging  Bucli  a  (juMtinn  forward,  Dr.  W.  Duncon  would 
have  iureniigutoii  the  fa(;tf,  nud  given  n  summary  of  thi'^m.  The 
iufluvuve  of  pnL^^'iinticy  uu  [ilitliiniii  was  still  ubscure;  it  waa  iiti- 
pFObkble  tliiit  ftny  eweepiiig  etittettieiit  i-aiild  bo  tande,  but  siicli 
AD  invcati^atioQ  might,  tbTow  tbe  cu»ce  mto  ccrtuin  groups,  dc- 

E ending  un  nui'h  fuctn  &b  tbo  kind  of  diecaitu  and  its  stage.  In 
is  KiuarkH  introduotory  to  tliu  diseustiioij,  tlie  PreHident  had  well 
dividdd  tbe  questions  raided  in  tlie  paper  into  jintliologicnl  and 
efehicaJ.  As  rogu'ded  the  former  we  htul  little  iu  the  nay  of  cer> 
taintf  ;  we  did  not  know  what  good  aburcion  itid,  nor  wh&t  harm 
jiregnancy  did.  Ab  regarded  the  ethical  ijueation,  he  thought  it 
wa»  well  recognised  that,  where  the  motlier'u  life  was  practically 
forfeited,  her  clniina,  an  aj;»iiiBfc  thoau  of  the  fietiis,  deatrved  leisa 
atl«ntioo.  The  claiisical  irjutauce  of  thiH  whm  tlmt  of  a  womnn 
Affected  with  oamrflr.  The  life  of  a  phthisical  woman  was  aluo 
generally  forfvited.  lu  contruift  to  this  we  had  bul-Ii  a  diaeaeu 
aa  eclampvia,  which  depeadi>d  ou  pregnancy,  and  which  would 
probably  ctaey  on  tho  coseatiou  of  pregnancy,  leaving  lbs  womaji 
(it  might  be  hoped)  m  porfoct  loaltb  and  with  a  fair  prospect  of 
remaining  !m>  in  a  future  pregnancy.  In  urgentcaaen  of  tliiasort 
it  wan  recognised  aa  a  proper  proceeding  to  proevire  abortion.  A 
SCDt«ric«  ill  Dr.  W.  Dancnn'*  paper  referring  to  the  production 
of  an  inferior  child  landed  ue  in  u  wry  doubtful  territory.  If 
we  were  to  procure  abortcon  iu  ciny  case  in  which  the  charactBr 
of  the  parents  vould  load  us  to  expect  a  child  meutully,  morally, 
or  pbyucally  undeairattle,  wc  should  have  our  hands  full.  Then, 
again,  how  many  times  ia  Dr.  W.  Duncan  prepared  to  procure 
abortion  in  the  aanio  woman '(  These  phthisical  women  often 
conceive  rery  rapidly.  How  soon  did  heeipeetthia  lady  to  return 
to  liim  with  a  nimilar  requeet?  If  he  was  right  this  time,  he  watt 
logically  boond  to  procure  abortion  for  her  as  often  ae  she  was 
piegoant.  Lastly,  the  apoaker  could  not  aee  any  reauoo  for 
"  aeeoucbcment  rapido"  (i.  e.  accouchement  force  without  cutting) 
in  auch  caacs.  Ke  thought  that,  with  all  our  antiseptic  precau- 
tiona,  such  a  procedure  must  inrolve  marked  additional  riak,  and 
that  the  woman  would  get  on  far  better  if  left  alone,  and  given 
chlurofonn  if  neceaaary,  during  the  second  atage  in  the  usual 
war. 

Ur.  MArrnEwa  Dttkcait  said  that  it  was  not  establiehed  that 

SregnanCy  injurumsly  alTectcd  the-  progrcmH  of  phthiais.  A  great 
cal  of  reuearch  had  been  made  on  the  aubject,  which  was  one  ei- 
tremely  difficult  of  aolulion — stmost  insoluble — the  result  being 
Dneertaioty  aa  to  whether  good  or  evil  came  from  pregnancy  in 
phthiaical  women.  Teriain  it  woh  that  auch  women  did  bear  fine 
tivaltby  children:  and  recent  intjuirim  as  in  the  infectivenesa  of 


14 


vB.BasA.Kcrs  1)1  cissB  or  phthisis. 


tubercle  did  not  lend  to  increaae  tb«  fear  of  danger  to  tbo  ftctus 
Trotn  its  coneumptive  mother.  He  would,  as  a  rule,  deprecate 
the  induction  of  abortion  or  premature  labour  in  ca«es  of  phthisis ; 
and  lie  litil  aot  look  with  favour  on  tli«  ra|)id  method  of  deliTery 
aa  described,  regarding  it  am  not  tlie  beat,  if  delivery  were  de- 
cided on. 

Dr.  AuAKU  ]toviH  thought  that  most  obstetricians  bad 
obBerved  thut  tiiu  process  of  lung-destructiou  in  phtliisis  during 
pregnonuy  wne  at  s.  etuDdetill,  but  becume  very  rnjiid  during  the 
subeequent  lactntion.  W»«  it  not,  therefore,  more  Ffltional  to 
prevent  lactation  than  ta  iaduce  abortion?  PoMibtj-  in  cseea  of 
pbtbiBiB,  during  the  Uter  moDths  ol'  pregnane^,  when  the  child 
was  viable,  and  dyapnoEa  becntne  urgent,  premature  labour  might 
be  wisely  indulged,  but  not  during  the  earlier  montlia. 

Dr.  Leitu  Katiee  had  seen  a  considerable  number  of  easea 
of  pregnancy  oecurriug  in  phthiaieal  women.  He  was  disin- 
clined to  accept  the  view  that  pregnanc;r  invariably  hastened 
the  progrees  of  phthisiB.  Although  be  might  mention  several 
caaes  illustrating  the  eonverse,  let  one  suffice.  A  patient  seen 
twelve  years  obo.  auffering  from  well-markedlung  disease — so  ill, 
indcud,  that  she  bad  practically  but  one  lung — fell  pregnant. 
Glrave  apprehensionH  were  entertained  as  to  the  prognosis. 
Happily  tlieae  were  contradicted  by  her  diittiuet  improvement 
during  pregnancy,  and  after  poirturition  she  coavaleaced  well. 
She  went  abroad,  was  still  aiive,  and  in  fairly  good  health.  When 
abortion  occurred  niLturally  in  a  phthisical  woman,  Tarioui 
pathological  factors  besides  the  general  aQffimia  had  to  be 
conaidered,  Abortion  in  a  phthisical  patient,  in  his  expe- 
rience, was  usually  a  very  grave  matter;  it  caused  great  strain 
on  the  palient'B  Htrengtb.  In  three  such  cases  he  had  met 
with,  the  lung  disease  progressed  rapidly,  and  the  deaths  were 
unqueHtionably  hiistened.  It  might  be  that  with  a  uterus  un* 
affected  with  local  disease,  and  in  an  early  stage  of  the  complaint, 
artificial  abortion  would  have  different  results.  Yet,uU  things  con- 
sidered, he  wae  not  prepared  to  accept  Dr.  William  Dancan'a  eug> 
gested  liine  of  treatment.     He  thought  a  waiting  policy  the  wisest. 

Dr.  Jamison  would  like  to  ask  Dr.  William  Duntion  if  ho 
himself  acquiesced  in  the  reasons  given  for  the  necossity  of  per- 
forming this  operation.  They  were  three.  First,  that  if  prema- 
ture labour  were  induced,  the  tubercular  diseaHe  from  which 
the  patient  was  auflcring  could  be  cured  by  hot  inhalations. 
Secondly,  that  the  children  of  phthisical  women  lived  a  very  short 
time  after  their  birth  ;  and  thirdly^  that  pregnancy  accelerated 
the  progress  of  phthisical  disease.  Dr.  Jamison  was  inclined  to 
join  itieue  on  each  of  these  assumptions.  Surely  to  speak  so  con- 
Itdently  of  the  cure  of  pbthisLs  byany  method  of  treatment,  even 
by  hot  iabalatioiie,  wna  not  in  accordanee  with  the  everyday 
ezpeiieoce  of  phthisis.    Ua  only  wished  pbtbiatB  were  as  easily 


FBSOKAirCT  IN  CASES   OF  PHrBieiS. 


15 


enrable.  That  the  children  of  phtbiiiical  mothers  only  lived  a 
ftbort  time  after  birth  was  &  atntemcDt  not  ia  Uarmoay  nitb  the 
CX|ienei]C«  of  every  one  in  this  room.  He  bad  kaowu  over  and 
over  ieAia  of  tlio  children  of  phtLleical  parvnte  growiag  up  to 
mIuU  Fife.  In  one  cnee  in  bis  exp&rieii«e  tire  healthy  children 
itero  bom  of  a  phthisical  motber.  Lastly,  Dr.  W.  DuDcaa  had 
admitted  that  tncva  were  no  alatiatJcs  to  prore  that  pre^aocy 
shortened  thE>  duration  of  phthiaical  disease,  but  he  would  like 
to  say  that  m^ftt  writers  held  just  the  contrary  view.  The  onJy 
'  French  writer,  of  any  uote,  who  thought  pregnancy  accelerftted 
phthisis  was  M.  GrisoUe.  Hia  own  impressioa  was  that  given 
two  phthiaical  women,  in  every  respect  equal  in  extent  of  diacaae, 
who  say  hod  uuly  tsix  muntlis  to  livv,  if  one  became  impreguatod 
she  would  live  over  nine  moathe.  He  wonid  like  to  point  out 
tbat  Dr.  William  Duncan  bad  not  told  them  whether  any  im. 

JroTomoQt  had'takoa  place  In  the  lungs  of  this  lady,  demooBtratod 
y  alteration  in  the  pbyaical  signs  after  the  operation.  lie 
attached  no  importance  to  the  statement  of  the  patient  that  she 
felt  qattfl  well,  a*  the  feelings  of  phthisical  people  were  the  most 
deceptive  things  in  the  whole  range  of  clinical  medicine.  There- 
fore, putting  all  together,  he  thought  no  cnac  had  been  made  out 
for  the  extension  o)'  this  operatiou,  nor  to  minimiBe  the  fet'liog 
that  it  wu  oQo  likely  to  be  attended  with  grave  abuae  aud 
danger. 

Dr.  ABBAnxM  "Wlllxce,  having  apologised  as  a  new  member 
■  JOT  obtruding  himself  on  the  f^ociety  otler  the  long  diseuBBJon, 
■aid  that  the  pubject  wbb  one  which  intereeted  him,  aud  lie  beg^d 
to  offer  Dr.   W.  Duncan  his  pergonal  thanks  for  starting  the 
qoeatioa.     He  congratulated  him  on  the  result  of  the  trualmvot 
in  the  isHividuol  caae,  but  cuold  not  accept  hia  general,  vob- 
diuioDS.     Ue  hod  had.  as  a  practitioner  of  midwil'en,-  and  as  ■ 
teacher  of  its  science,  conaidemble  difficulty  in  formulating  the 
principles  of  treatment  necessary  for  the  conduct  of  hia  practice 
aa  well  aa  for  the  inatrnction  of  etudenta.     No  doubt  a  great  deal 
had  been  written  on  phthisia  complifating  pregnancy,  eipreitsing 
▼ary  discordant  opinions  as  to  the  effect  of  pregnancy  and  par- 
tuntiOD  oo  tho  progress  of  phthisis  pulinoD&lis  j  but,  bo  far  ae  ho 
knew,  there  were  not  any  Indicationa  given  in  regard  to  treat- 
ment in  tho  accopted  test-books  of  midwifery.     CoQHidorin^  the 
itdvftnce  made  during  recent  ycora  in  tho  inveatigatioD  of  the 
IjMthology  and  treatment  of  phthisiB,  he  thought  that  this  par* 
[ticalar  luhject  was  deserving  of  Eeriousconsideratioa.     He  depre- 
'eated  the  idea  of  the  report  of  the  discussion  of  this  eveniiig  going 
librtb  to  the  profession  as  an  ezpreasion  of  tlie  views  of  this 
Society,  whose  influence  wna  ao  esbeu8ivo,aad  suggested  thnt  the 
•abject  lay,  aa  it  were,  on  the  border-land  of  pure  medicine  aud 
midwifery,  and  ought  not  to  be  approached  from  tbe  etandpoint 


16 


PKBONINCV    IN   CASKS   OW  PHTHISIS. 


of  tlie  obsfetric  specioJist  merely,  but  re<]uired  to  be  looked  ftt  in 
nil  Hh  uept'cti. 

Dr.  William  Dditcan  {in  reply)  saitJ  ho  was  very  glaii  tfa« 
question  had  evoked  such  im  active  diBcuHHion,  but  nt  tho  same 
time  be  coulil  uot  cjuits  agree  with  tho  opinions  eipn^sKtfd  by  the 
variouB  apealterB.  He  must  diaecDt  from  th?  sssertiou  that 
"  prfigtunicy  sLould  uot  he  termiuated  unlese  it  threateaed  tbe 
palieut" s  life;  "  and  beaivDtioned  the  caseof  apatieut  id  the  Mid* 
dlesex  Hospital  who  last  year  bad  severe  puer|>erfll  eclampfiia, 
and  recently,  being  6ve  raonths  pregnant,  was  readmitted  with 
acuie  Qepl].riti&,  double  uptic  neuritia,  and  retinal  bsmorrhages. 
The  ophthalmic  niirgefin  oaving  said  that  if  tbe  pregnancy  were 
allonud  to  f^n  on  tho  patient  would  probably  bifoome  blind,  Dr. 
Duncaa  bad  no  he^itatioa  in  emptying  tbe  uterus.  He  thought  that 
the  induction  of  abortion  gave  adietiuctadFitntage  by  doingaway 
nritb  the  dangere  connected  with  parturitioii  and  the  puerperium. 
He  did  not,  of  course,  mean  that  alt  eases  of  phthisis  cooiplicatinf; 
pregnancy  cnlled  for  interference,  but  each  crhd  inuat  be  judged 
or  its  merits,  and  after  careful  conHultation  with  another  phyaicriiiH, 
who  abould  share  tbe  reapou&ibiiity-  Neither  did  he  mean  that, 
hBving  oace  terminated  pregnancy  in  a  given  cAse,  the  same  treat- 
ment should  be  pumuod  if  impregnation  eubaeijueotly  took  place. 
On  the  ijontrary,  if  tSio  patient  neglBL-ted  the  warning  given  her, 
she  (being  entitled  to  ehoose]  took  the  reapongibilily,  and  must 
submit  to  the  rieka.  Dr.  Duncan  regretted  he  could  give  no 
statistics,  either  proving  that  life  is  shortened  in  these  cases,  or 
showing  thee^octof  pregnaacy  on  a  phthiaical  woman;  but  he 
was  one  of  thoee  who  did  not  believe  much  in  iBtativtica  :  hia 
statements  on  tbeee  points  were  those  given  in  all  the  leading 
works  on  obstetrics. 


^E  CASKH  OP  PUERPERAL  ECLAMPSIA,  ESPE- 
CIALLY ILLUSTRATING  TUE  TEMPERATURE 
AND  UKINE  IN  THIS   DISEASE. 

By  G.  Ekmesp  Herman,  M.B.Lontl.,  F.R.C.P., 
oonBTKio  PuraiciAK  n>  iiii  loxdoji  uosfitix- 


(Retvired  Octnfacr  24lh.  1B89.) 

Fttb  iwies  arc  d«t&il«d,  of  wbich  thp  chiof  fe&tures  am  u 
fullows : 

O&sB  L — First  prcgnivncy;  premonitory  ejniptouiB  a  few 
hours  only  before  Btn-,  coiivulHiuns  coiiiiiii.-uciiit{  during  first 
ttugo  of  labour  At  term,  not  ceasing  witli  delivery,  ceasing 
aEt^r  morphia ;  bovpii  tils  hi  all ;  tcmpomture  rising  Blightly 
during  fits,  falling  after  c^sHation  of  fits;  diminution  in  (]iiuutity 
of  urino  tluriD^  fit*  j  lUureiuH  after  dt-Uvery  und  CL'sstliwu  of 
fits;  uriue  during  Uta  uvarly  stflid  wilb  iilbumvti  (mucli  para- 
globulin),  blood,  and  oaala  ;  rapid  dieappf^araaccof  albumen  and 
blood  aft«r  dcliv«ry;  diiaioisbcd  elimination  of  urea  during 
fits ;  increased  elimination  of  urea  following  deliver}-.  Gompltit« 
wooTery. 

Cub  2.— Second  pregnancy ;  prouionitory  symptoniB  throe 
weeks  before  fits;  intm-aterino  death  of  ftctua  ;  fiu  coming  on 
at  «igbt  iuontb»'  pri'giiuncy  ;  eight  fits ;  fits  cenAing  after 
morphia,  and  before  delivei^ ;  slight  pyrexia,  continuing  four 
boura  after  lunt  Ht,  tlien  ubutiug  ;  polyuria  tliruu^^Luut,  t^ruipo 
rarily  iucruased  afti^r  delivery;  uriue  contiuuiu);  liulf  it;i  bulk 
of  albumen  (much  paraglobulin)  ;  iDcreaee  of  albuiueu  SvHoiriag 
flt8 ;  albumen  diminiiihed  after  delivery,  but  still  persiating 
montlis  afterwards;    diminution    of  urea-elimtuatiuD   during 

VOL.  XXXII.  2 


IS 


PDBBPEBAL   ECL&MPBU. 


fits;  restomtiou  of  uri^a-eicretioD  to  normal,  commeticitig  afttt 
ceseatioD  of  fits  ;  retinitia  albuiuinurica, 

Ca£B  8. — First  pregnancy  ;  jiremonitory  symptoms  forty -eight 
liours  before  onset  of  6ta  at  five  months'  preynauoy  ;  about 
BixteC'D  fitM  ;  BiioulimuoUB  premature  delivery  ;  urine  solid  witt 
nlbuQien  (lai^ely  parEiglokulin)  ;  ufissatiou  of  fits,  fall  of  tempe- 
rature, a.nd  diminution  in  gjilbiiminurin  following  adminiatriLtion 
of  morpbia,  and  preceding  delivery  ;  cTirainution  oE  uriuu  and  of 
urea-excretiuR  (botU  absolute  and  iu  proportion  to  the  urine) 
during  period  of  fits;  r«-eatahlishment  of  urine  and  urea- 
excretion,  coumeQciag  after  cessntloa  of  Qts  and  before  de- 
litery.    Recovery. 

Case  4. — Tenth  pregnancy  ;  symptoma  a  week  Iwfore  fita,  at 
aeveu  uiontba'  pregntincy  ;  tbree  days'  trciktmciit  by  milk  diet  in 
hospital  brfore  fite;  retiaitis  ^  (our  fits  only;  morpliia  givoD 
after  Becond  lit ;  death  by  coma  live  hours  after  last  fit ;  sub- 
normnl  temperature  ;  fits  preceded  and  acf/ompaniod  by  slightly 
inereiLBud  diuresiK ;  albuminuria  diminished  by  rest  and  niilk 
diet ;  fits  accom])aiued  and  followed  by  increase  of  albuminuria 
aud  hroniiLturia;  steady  diminution  in  urear-pprcoutage,  pre- 
ceding fit*  flod  continuing  till  death;  abeolute  nrea-excrc-tion 
diminished  throughout,  but  no  greater  diminutiou  preceding  or 
accompanying  Ets.    No  autopsy, 

Oasb  5,— First  pregnancy  ;  xymptums  about  tbirty-&ix  bours 
before  fitb,  at.  eight  mouths'  pregnancy  ;  intra- uterine  death  of 
EcetiUi  twenty -four  fits  iu  all,  extending  over  sixty  hours, 
csaHtng  "before  delivery  ;  delirium  for  forty-eight  hours  after 
fits;  slight  pyrexia,  subsidiug  before  vessution  of  fits;  during 
period  of  earlit-rfita  urine  solid  with  albumen, and  diminished  in 
quantity,  but  percentage  of  urea  not  diminished;  imorease  in 
quantity  of  uiine  and  percenti^  of  urea,  and  diminutiou  of 
albuminuria  before  ceesatton  of  fita.     Complete  recovery. 

The  author  points  out  the  diSerences  between  the  cases  tliem- 
selres  and  betweoa  tUem  and  other  published  cases,  and  draws 
the  iufereiicc  that  puerpertbl  uclumpsiu  is  a  diseast;  nut  haviug 
a  uniform  clinical  lustK>ry  any  more  than  a  uniform  morbid 
anatomy. 


FDERPKBAL   BCLAHPSU.  19 

In  vol.  xiix  of  tlie  '  Transactions  *  of  fcliis  Society  I  con- 
tribnted  a  paper  in  which,  two  cases  o£  puerperal  Bclampsia 
were  related.  They  were  puWished  because  the  course 
of  the  renal  fimction  had  beeu  observed  with  exceptioual 
care.  I  now  submit  five  more  cases  in  wliich  aimilikr 
obserratioiu  hare  been  made. 

Ca81  I . — Primigravida  ;  premonitory  ttymptoim  a  few  hiyitra 
oniy  befvre  fite  ;  eonvulidons  i-omviencing  during  Jirst 
sUigo  of  labotiT  at  term,  noi  eeaeiiig  tcith  delivf^ry,  eeaa- 
ing  after  morphia  ;  nevon  fts  in  nit;  temfcraturo  riinng 
Uliijhtly  during ftg,  falling  after  con^ation  i>f  Jtls ;  divii- 
ntition  in  quantitif  of  urine  during  Jits ;  diuresia  after 
delivery  antl  ce-i'-'tation  of  jits  ;  urine  during  fits  ui'urly 
golid  with  ulhumen  («iw<-A  of  it  paraglohuHn),  blood, 
and  ra»t9  ;  rapid  diaappearanee  of  aliiunien  and  hlood 
after  dnlivery  ;  diminiahtd  excretion  of  urea  during  fin  ; 
incrtaaed  diureeis  and  excretion  af  urea  during  lying-in 
period ;  Mtnpfode  recovery. 

C.  L— ,  aged  22,  single,  preg^nsnt  with  her  first  child, 
admitted  into  the  General  Ljing-in  Uospitul,  -July  2tith, 
1888.  I  have  to  thnnk  ]^[r.  U.  A.  Pratt,  house  physician, 
for  the  notes  of  the  case  and  the  aualyses  of  the  urine. 

Previous  hitlory. — Said  to  have  had  scarlet  fever  twice 
and  meaales  twice  when  youug;  each  time  recovery  good. 
No  other  ill  D0B8.  Begati  to  menstrutito  at  fourteen  ;  always 
regular.  Slight  pain  preceded  flow.  Last  menatruatod 
from  October  20th  to  October  24th,  1887 ;  duration  five 
days  ;  (|uaDtity  as  utiunl.  During  Erst  two  months  of  pri-'g* 
lancy  patient  suffered  greatly  from  retching  and  vomiting 
'  ID  the  morning  immediately  on  rising.  Slight  swelling 
of  ankles  duriug  first  two  months  of  pregnancy  ;  none  since. 
During  remainder  of  pregnancy  felt  very  well.  Has  had 
a  white  vagtnul  diucharge  for  tbo  past  three  weeks.  Move- 
ments of  child  Brut  felt  in  February,  1888. 

Hittory  immediately  precediity  admission. — Falieut'e 
aooouul  was  that  en  July  20tb,  1888,  she  went  to  bed. 


so 


PtJtRrKIUt.    KCLJUirsU.. 


feeling  bb  osualj  at  1  B.m.  July  21  st,  woke  feeling  slight 
pain  in  abdomen,  unci  water  running  away.  Came  to 
hospital,  but  was  stnt  back  as  not  in  labour.  At  nooa* 
21at,  patient  felt  very  ill,  "  ill  all  over/'  but  had  no  pain. 
At  I  p.m.  alight  "  show."     Admitted  1.30  p.m. 

Mother'*  account. — Patient  has  seemed  battor  than  aennl 
dnrirg  pregnancy  till  the  morning  of  2l8t,  when  sbo  com- 
plained of  iieadache  ;  she  also  put  her  baud  to  the  front  of 
her  chest,  eajiug  ehe  bad  a  pain  there  through  to  her 
shoulderB,  a  "  sinking  pain."  Patient  was  eick  three  or 
four  times  during  the  morning,  "the  vomit  being  streaked 
with  blood."  The  last  time  there  was  "  only  bile,"  Her 
bowels  wero  open  twice  before  leaving  home. 

She  states  that  she  was  a,  "  funny  bloish  colour'"  all 
the  morning. 

Has  ne?er  had  fits ;  there  ia  no  family  history  of  epi- 
lepsy.     Never  complained  of  her  sight. 

On  admisRiion,  July  'il^t,  1888,  1.30  p.m.,  patient  pale^ 
but  mot  aniemic.  Well  developed.  Nothing  strange 
noticed  in  patient. 

VaQinal  e-raminaiion. — Cervical  canal  obliterated,  08  sixa 
o(  florin,  edges  thin,  dilatable.  Blight  show.  Vertex  ia 
catity  of  pelvis  in  second  position.  Membranes  rnptured. 
Doucho  and  oncma  ordered,  the  latter  acting  freely. 
Patient  passed  uriue  several  times,  which  was  described 
by  nurse  as  being  normal  in  appearance. 

Pains  regular  and  fairly  strong,  iiiercasod  after  enema. 
At  4.15  p.m.,  while  patient  was  on  the  night-stool  for  the 
purpose  of  pasaing  water,  she  was  suddenly  seized  with 
twitobing  of  face  and  hands,  and  became  very  stiff.  No 
oiy.  A  nnrsc  who  was  standing  at  patient's  sido  imme- 
diately placed  her  on  iho  floor  and  prevented  her  from 
biting  her  tongae.  The  twitcliiuga  lasted  throe  minutea  ; 
patient  then  began  to  foam  at  the  laoubh,  becoming  ahghtly 
livid,  and  remained  in  a  drowHy  condition  about  half  an 
hour  ;  she  then  had  a  short  period  of  complete  conscious* 
ness,  anewering  questions  readily. 

During  the  fit  the  conjunctival  were  iasensitiro ;  the 


POBUFCBAI   ECtAMPgl 


pupils  were  equal  ami  of  moderate  aiap,  reacting  refldilj" 
to  light.  4.30  p.m.,  Chloral  Hydrate  and  I'ot.  Brom.  aa 
gr.  XXI,  given  per  rectum.  5  p.m.,  second  fit,  lasted  tlirco 
minutes,  affocting  botb  sides  of  face  and  body.  Remainod 
drowsy  about  ten  minutes.  After  fit  pulse  lOO,  rcct&l 
temperature  998'^.  6.5  p.m.,  fit.  Juration  three  minutes. 
PuUe  98,  temp.  39'8°.  7  p.m.,  fit,  duration  four  minutes. 
Pulse  106,  temp.  100°.  7.45  p.m.,  fit,  auratiou  four 
minutes.      Pulse  120,  temp.  100-6°. 

The  head  having  advanced  to  the  pelvic  outlet,  at 
8.30  p.m.  chloruferm  waa  given  and  forceps  applied. 
Child  living.  9.3  p.m.,  fit,  stronger  than  former  odcs, 
daration  four  minutes.  PuUe  Iltj,  temp.  100*8°.  10.12 
p.m.,  fit,  stronger,  duration  three  minutes.  Pulso  132, 
temp.  hOO'S".  10.40  p.m..  Been  by  Dr.  Herman,  who 
ordered  hypodermic  injection  of  morphia,  gr.  J.  11  p.m., 
sleeping. 

July  22nd. — Patient  etill  sleeping,  haa  taken  food  ia 
{orm  of  milk  and  beef-tea  freely  when  roused.  No  moro 
iita. 

23rd. — About  2.30  p-m .  yesterday  afternoon  patient  woke 
up  and  asked  if  she  might  see  her  baby,  auU  osprcseed 
herself  as  feeling  very  well.  11  a.m.,  Pulr.  Jalapoo  Co., 
gr.  zxx,  given.  8  p.m-,  rep.  pulv.  12  midnight,  bowels 
not  acted,  enema  ordered.  Has  taken  milk  aud  beef-tea 
freely. 

24>th. — Very  good  night.  Enema  was  repeated  in  the 
early  morning,  but  only  acted  slightly.  10  a.m.,  Pulv. 
Jalapte  Co.  ^j.  Patient  ^ays  she  feels  very  well,  no  head< 
ache. 

Oiihihiilrrtuscupic  examination. — Nothing  abnormnl  de- 
tected.     Takes  food  well, 

25th. — Steeps  well.  Aftor  two  cuoiuas  bowels  acted 
freely.  Patient  is  now  taking  Mag.  >Sulph.  5]  in  a  tnijc- 
taro  three  times  a  day.  There  are  bruises  on  arms  and 
logs,  caused  during  the  fits. 

2l3th. — Patient  coutiuues  well.  No  headache.  This 
morning  her  arms  aud  upper  part  of  chc«t  are  covered  with 


PDBHPgBAI.    ECLAMPSIA. 


23 


a  vesiculo-papulfip  rash,  which  itches  greatly,  BowoU 
veiy  obstinate,  only  one  slight  motion  nfter  several  doses 
of  Mist.  Sal.  Aper.,  Eneraa,  and  01.  Crotouia  ny. 

80th. — Patient  very  well ;  was  np  yesterday  for  first 
'time.  Bowels  still  obatiuate,  open  once  jcHterday  after 
01.  Ricini  ,=fj,  which  was  repeated  in  two  hours. 

August  5th. — Discharged. 

Tetttpcraturc, — On  admission  tho  temperature  was  07*4", 
Aft«r  first  fit  it  reached  lOO'-t'  in  the  rectum.  AJt«r 
second  and  third  fits  it  reached  BS-S"  in  the  rectum.  It 
was  taken  just  hefore  fourth  fit  and  found  to  bo  100"4°, 
'  after  the  fit  1 00°.  After  fifth  fit  it  reached  100-6°.  After 
delivery  it  was  lOO'S",  and  remained  the  same  after  nixth 
and  seventh  fits.  From  10  p.m.  on  the  21at  it  wuk  taken 
hourly  till  midnight  on  the  28rd.  It  continued  at  lOO'S" 
(or  three  hours  after  last  fit,  and  then  gradually  fell  ; 
after  thia  it  nevor  rose  above  100"  during  patient's  stay 
in  hospital. 

Urijif, — All  the  urine  waa  saved  and  examined  during- 
patient's  stay  in  the  hospital,  with  the  exception  o£  the 
80th,  when  Eome  was  logt,  tlie  nurse  failing  to  pass  the 
catheter  hefore  Btool.  The  urea  was  estimated  with 
Squihb's  apparatus,  aud  ou  several  occasions  was  inde- 
pendently examined  by  Dr.  Herman  with  Jerrard's  appa- 
ratus, and  the  results  found  practically  to  agree  with  those 
given  by  Squibb's  process.  For  the  first  thirty  hours  the 
'-nrine  woa  hourly  examined  quantitatively  for  urea:  after 
this  it  waa  all  mixed  together  aud  examined  onoe  in  the 
twenty-four  hours. 

At  1 1  p.m.,  July  21&t,  the  bladder  was  found  to  contain 
32  c.c.  of  urine,  at  12  midnight  42  cc.  When  the  catheter 
was  pn8.?od  at  2  a.m.,  July  22nd,  uo  urine  could  be  ob- 
tained, at  3  a.m.  only  10  c.c.  found  in  bladder,  and  none 
at  4  a.m.  After  this  the  quantity  varied  from  4-2  c.c.  to 
134  c.c,  with  the  exception  of  1 1  p.m.  on  22ud,  when  only 
10  c.c.  could  be  obtained. 

The  quatitUy  of  urine  passed  per  diem  varied  from 
18  to  55  OS.,  the  daily  averago  being  30  oz.     The  first 


24 


PCERFBKAL   KCLAMPSU. 


dny  after  delivery  85  oz.  were  passed,  on  the  fifth  day 
49  OK.,  but  OD  tlie  sixth  day  only  18  os.  were  paatied  m 
twenty-four  hours.  On  the  ninth  day  only  8  oz.  o(  urine 
were  Kaved,  a  considerable  quantity  being  lost  at  stool  on 
this  day. 

Hfr-cific  gravity — The  ep.  gr.  of  the  urine  paased  after 
the  last  fit  was  1030,  this  heing  the  highest  recorded.  Ono 
fiamplo  o£  urino  passed  the  second  dfty  after  delivery  had 
a  sp,  gr.  of  1005  ;  this  was  not  accompanied  by  any  marked 
increase  in  quantity  seerotod.  After  this  tlio  sp.  gr. 
varied  from  1008  to  1020,  the  average  being  1013. 

Colour. — All  the  urine  secreted  while  patient  was  having 
fits,  and  for  two  hours  after  the  last  fit,  was  port-wine 
coloured.  The  sample  of  ui-iue  drawn  off  three  Iioura  after 
last  fit  wa»  a  bright  red  colour.  Ten  hours  after  last  tit 
the  urine  wae  amber  colour. 

Blood. — The  quantity  of  blood  in  urine  diminished 
rapidly  after  last  tit,  so  that  none  could  be  detected  with 
the  cyo  ten  honre  after  cessation  of  fits,  but  the  ozonic 
ether  and  gnaiaeura  test  gave  a  faint  bine  ring  eleven 
hours  after  last  fit ;  none  could  he  detected  hy  this  method 
twelve  hours  after. 

Casts. — A  few  granular  blood  CHsts  were  found  in  the 
Si-st  aaraplea  of  urine,  but  they  were  uf  ver  nuinerous,  and 
none  were  found  after  the  first  day. 

AUmmen. — The  ariiie  secreted  while  patient  was  having 
ftta,  and  for  next  two  honrs,  turned  solid  or  nearly  solid 
on  boiling.  Tlic  qnantity  of  albumen  then  rapidly  dimin- 
ished, BO  that  in  three  hours  after  the  last  fit  it  only 
contained  one-third  albumen,  a  faint  cloud  only  being 
fonnd  Bpventeen  hours  aftoi-  last  fit. 

Four  samples  of  urine  were  osaniiued  after  having  been 
shaken  up  with  sulpliate  of  magnesia  and  filtered.  The 
ilri«t  sample  examined  in  this  way  was  drawn  off  one  hour 
after  1a.st  fit,  and  after  the  separation  of  the  paraglobnlin 
gave  only  half  as  much  [n-ccipitate  ati  that  containing  both 
serum-ulbumen  and  paraglobulin. 

The  next  sample  was  drawn  off  eleren  houra  after  laat 


rttERPESAL  souvrsu.. 


25 


fit,  and  f^aTfi  a  precipitate  of  one-sixteenth  albumen,  After 
eepftration  o£  paraglobulin  only  a  famt  cloud  could  bo 
obtAinect.  Tho  remRining  tn-o  specimens  each  g&vo  a  faint 
cloud  on  boiling  both  before  and  after  treating  thom  with 
sulphate  of  magnesici,  but  not  enough  to  deposit  at  the 
bottom  of  the  test-tube.  No  tiaco  of  albumen  could  be 
detected  wheu  patient  was  discharged  from  the  hospital. 

Una.' — The  uriijc  secreted  during  period  of  fits  con- 
tained 2-16,  2'09,  and  2-36  per  cent,  of  urea.  In  the  first 
twenty-four  hoHrs  after  delivery  the  hourly  percentage  of 
urea  excreted  varied  greatly,  the  lowest  beiug  1*7G  per 
cent,  and  the  highest  2-84  percent.  In  the  second  twcnty- 
foor  hours  the  hourly  secretion  reached  3'38  per  cent.  In 
the  first  twenty-four  hours  after  the  fits  had  ceased,  the 
quantity  of  urea  soeroted  was  457  grains  ;  on  the  second 
day  310  graitifi.  On  the  sixth  day  after  delivery  only 
1 76  graiiiM  wen*  secreted,  which  wr»  much  below  the 
quantity  secreted  on  any  other  day  during  patient's  stay 
in  hospital.  The  kind  of  food  taken  and  the  getting  up  of 
the  patient  had  little  or  ao  effect  on  the  quantity  of  urea 
secreted. 

October  2'ith,  18S9. — Child  died  from  con vnlsioue,  aged 
two  months.  T^ticnt  now  thinks  herself  quite  well. 
Married  September  15tli,  1889.  Last  menBtrnation  July 
7th.  Catameuia  regular  since  discharge,  no  pain.  Now 
thinks  herself  four  months  pregnant.  About  as  sick  this 
pregnancy  aa  in  the  former  pregnancy.  Urine  free  from 
albumen. 


This  case  fBTOurs  tho  opinion  that  the  pyrexia  which 
ftocsompanieB  some  cases  of  eclampsia  h  duo  to  tho  fits. 
While  this  patient  was  having  fits  the  temp[>rature  steadily 
althongh  slightly  rose;  and  when  the  fits  had  ceased  itas 
Bteadtly  fell.  Tlie  lempemturedttring  the  lying-in  period 
does  not  call  for  special  remark. 

The  case  also  shows  great  diminution  in  the  quantity 
of  urine,  and  in  tho  amoanl  of  urea  excreted  during  the 


26 


PUERPERAL    HCL11IF8I1. 


fits,  The  qunntity  of  urine  and  amoaat  of  urea  7aried 
nearly  pari  paa^u.  After  tlie  fits  the  excretion  gradunlly 
began  to  riao,  but  its  re-establishment  did  not  scora  to 
begiu  until  six  liours  after  the  tits  had  ceased.  The  last 
fit  was  at  10,12  p.m.  Between  .3  and  4  a.m.  no  urino  wag 
passed  into  the  bladder.  Between  4  and  5  a,m.  urine 
again  (lowed  into  tlie  bkdder,  and  from  this  lime  the  only 
change  which  took  place  was  in  the  direction  of  increase. 

The  re-establiahinent  of  the  excretion  of  nrine  is  there* 
fore  not  a  condittoa  which  necessatily  precedes  the  cessa- 
tion of  the  GtB.  The  fits  cease  Brst,  and  then,  after  an 
iiitervftlj  the  excretion  of  urea  Bgain  risttg  to  the  normal. 

Ill  the  five  (Jays  following  the  re-establiahmeut  of  the 
urinary  Becrottou  thore  was  an  excretion  rnth^r  exceeding 
that  which  is  usual  in  a  healthj  person  \ymg  in  bed  on 
low  diet.  This  diuresis  and  augmented  urea- excretion 
reached  its  height  on  the  third  and  fourth  daya  after 
delivery;  on  third  day  -iO  oz.  of  urine,  containing  520  grains 
of  area,  were  passed. 

Daring  the  stress  of  the  disease  the  hourly  excretion 
of  urea  varied  much,  without  tho  cause  of  such  -variation 
being  discovered. 

Daring  the  lying-in  period' there  were  great  variation* 
in  the  amount  of  urine  ou  different  davSj  but  no  cause  for 
these  variationa  was  perceived. 


Case    2. — Beeundigravida ;  jiremrniitirry    sympfnvia    three 

weet«  he/ore  JUtt ;  JUx  raming  on  at  eight  mimtli^ 
preffnanctj  ;  intra •■iiterCne  death  of  /(.tine  ;  tight  Jitu  ; 
Jits  teaming  after  worphiu,  hefore  delivery;  slight 
pyrexia,  cuvfimiing  four  hour/'  iifler  last  ft,  then 
falling ;  polyuria  Ikroughout,  temporarily  increaffed 
after  delivery  ;  urine  containing  half  its  hvlk  of  aibV' 
men,  largely  paraglobiiitn ;  increase  of  olhuminuria 
fnliuwivy  fils ;  albuminuria  ff-imininkud  after  deliverif, 
biif.  Ktill  permMitiff  seven  mtytitha  nftenoardg  j  dtmtnii- 
tion  in   excretion  of  vrea    during  jtt$ ;   reatoration  of 


PPBUPERAL   ICL4MP3U. 


27 


normal  UTeu'eUjiiiitatiun  i-u-miiiettc-iiig  after  cessation 
of  Jits  ;  retinitis  aViuminurira.  (Tlie  notes  of  the  onso 
were  taken  by  Dr.  H.  G.  Lys,  Kesidt-nt  AccouclieuTj 
and  Mr.  J.  H.  Wilkinsok,  Cliuicol  Clerk.) 

C.  K— •,  aged  2<%  admitted  into  the  Londou  Hospital 
January  ICtU,  1880. 

Patient  had  never  had  fits  before,  nor  h&d  &uy  of  her 
relatives  suffered  from  fits. 

Slie  had  had  one  child  twelve  months  ago,  and  during 
the  last  six  wwuka  of  progiiiiuuy  with  it  suffered  from 
"dropsy."  WLva  aduiitted  she  believed  herself  to  be 
eight  months  pregnant.  She  had  tiufferod  frem  morniiig 
Tomiting  throughout  the  whole  pregnancy,  worse  for  the 
last  two  months.  Between  two  and  three  months  ago  her 
feet  began  to  swel),  and  for  the  last  three  weeks  her  eye- 
lids and  face  bad  been  puffy.  For  three  weeks  she  had 
complaiued  very  much  of  headache.  Three  weeks  ago  she 
had  a  fright.  On  December  26th  the  patient  (who  had 
obtained  a  card  entitling  her  to  the  attendance  of  a  mater> 
nity  pnpil  in  her  confinement)  sent  to  the  hospital  under 
tlio  idea  that  she  was  in  labour.  The  student  who  went 
to  800  her  found  no  indication  of  labour,  but  advised  Iter 
to  come  in  on  account  of  the  dropsy.  For  the  last  two 
■weeka  she  had  slept  badly.  About  a  week  ago  she  com- 
plained  of  not  being  ablo  to  mo,  and  ever  since  then  ber 
keight  had  been  getting  worse.  Ou  the  morning  of  admits 
sion  she  did  not  seem  able  to  ehq  a  light.  She  alao 
complained  of  "  water  in  her  eyes  and  at  the  back  of 
her  head."  Throughout  the  night  before  admission  she 
'  wan  delirious — her  husband  said  "  raving," — getting  out 
of  bed  and  walking  about;  she  did  not  recognise  her 
husband  that  night.  She  had  nover  complained  of  epi- 
gaatric  pain. 

At  G  a.m.  on  the  morning  of  admission  the  patient  fell 
down  in  a  fit  in  her  room.  A  quarter  of  an  hour  after 
ahe  bad  another  lit  j  and  a  quarter  of  an  hoar  after  that 
a  third    fit.      Hhc    had  two  mure    fits   before   admission, 


S8 


PUBEtI>ERA.L   m!.\MP3lk, 


the  last  one  being  in  the  cab  nt  the  gates  of   the  hos- 
pital. 

She  wns  Admitted  at  10  a.m.,  January  Itith.  On 
admission  sho  was  vory  restless,  continually  turning'  from 
side  to  side  and  on  to  her  KancU  and  knees.  A.  quarter 
of  an  hour  after  admisaiou  she  had  a  (it.  After  this  she 
Iny  more  quietly,  breatliing  heavily.  Ten  minntes  after- 
wards »he  had  a  eerenth  St.  During  this  the  adminis- 
tration of  chloroform  was  begun,  with  the  result  of  appa- 
rently checking  the  fit.  After  this  the  putieut  breathed 
heavily  for  about  fifteen  minutes,  and  then  sfemed  to 
sleep  quietly,  only  crying  out  at  inten-als.  At  1 1  a.m.  an 
enema  of  sulphate  of  magnesia  was  giveUj  but  produced 
no  effect.  At  n.4-'>a.ni.  a  simple  euema  was  given,  which 
rBturned  as  it  came.  At  noon  the  patient  bad  so  far 
recorered  coiiBciousiieaa  as  to  ask  where  she  was  and 
where  her  mother  waa.  After  this  she  became  more 
restless  and  violent.  At  2  p.m.  an  eueraa  was  givea  con* 
taining  Chloral  588.  and  Pot.  Bromid.  ^sb  in  some  milk  ; 
and  -]^  gr.  o£  pilocarpin  was  injected  siibcntaneously. 
Abont  3  p.m.  the  patient  slept  for  half  an  hour.  At 
4  p.m.  the  euema  was  repeated,  and  she  became  qnieter. 
Before  this  she  was  so  violent  that  she  had  to  be  held 
down. 

Abont  4.30  p.m,  ehe  was  seen  by  Dr.  Homian,  and  the 
folluwing  note  was  made  : — Potient  very  restlesB  ;  breath- 
ing with  short  calchiug  inspirations  and  long  hissing  ex- 
pirations. Pupils  were  widely  dilated  before  the  admiuis- 
tration  o£  chloroform.  Uterus  hard,  containing  but  little 
liqnor  amnii  ;  fundus  reaching  two  inches  above  the 
umbilicus.  Much  oedema  of  legs,  flight  oE  abdominal 
■wall.  On  Tiigiunl  exaiuiuatioa  cei-vis  softened,  undilated. 
Pulse  regular,  l^t)  per  minute,  full  aud  hard.  Cardiac 
dulness  reaehes  to  the  left,  just  outside  nipple  Hue.  No 
murmur.  No  abnormal  sounds  over  Sunga.  Liver  dnl- 
nees  reaches  from  lower  border  of  Hixth  rib  to  costal 
margins.      Splenic  dulness  not  increased. 

At  4.40  p.m.  the  patient  had  another  fit.      Half  a  grain 


PDSRPBBAL   tCLXMniA. 


29 


ofmorpbia  was  tlien  given  hjpodermicallj.  8  p.tn.— Since 
tbe  tnorpliia  injection  patient  has  been  sleepiDg  cjuietly, 
with  noisy  breatliing;  pupils  small.  Passage  of  CHtheber 
provokes  violent  movements  of  resistance.  Os  uteri  size  of 
a  tlorii),  membranes  unruptured.  8.45  p.m.,  patient  very 
violent  wIienroua«d;  Morph,  gr.  ^  and  Atropiu  gp.  jjV  g'™" 
hypodermicully.  10.30  p.m. — Patient  slept  after  last  ia- 
jcction  tiU  t*n  o'clock,  then  became  so  restless  tliot  she  had 
to  be  hold  down  toprerent  her  from  flinging  herself  out  of 
bed.  Chloroform  was  given.  The  ob  was  funnd  almost 
fully  dilated,  the  membranes  nnrnptnred ;  the  Lri'ech  pro- 
senting,  dor«o<>poKterior.  At  1 1  p.m.  the  membraueH  were 
ruptured,  and  delivery  easily  effected.  The  placenta  waa 
expressed  without  difficulty,  and  there  was  no  unusual 
beemorrhaige.  Fcctua  decomposing.  After  delivery  the 
chloroform -lUiBBstliesi a  passed  into  sound  sleep.  Slie 
fllepb  continuounty  throughout  the  night,  only  rousing 
Trhen  the  catheter  was  parsed. 

17th,  9  a.m. — Patient  eat  up,  &aid  she  was  dry,  and 
asked  where  she  was.  Between  0  and  11  a.m.  took  half 
a  pint  of  milk.  Throughout  the  rest  of  the  day  was  quite 
qniet  and  rational,  not  even  relenting  tho  catheter.  She 
continued  to  take  milk  well,  and  excepting  when  roused 
for  thia  purpose  and  the  catheter,  tilept  throughout  the 
day.  She  recognised  her  friend?.  There  was  much 
cedema  of  face,  neck,  and  legs,  although  the  latter  had 
diotiQisbed  in  size  since  admission. 

18tb. — Slept  well  through  tho  night.  Occasional  coiigli 
throughoat  night  and  to-day.  (Edema  less.  Pulse  120 
to  139,  Ophthalmoscopic  examination  made,  and  appear- 
ances of  neoro-retinitis  found.  Slept  throughout  tho  day 
except  when  ronned.  Bowels  open  twice,  loose.  No 
vomiting,  no  complaint  of  hcadnche.  Occa-sional  rhouchi 
in  longs,  no  other  physical  signs.      Still  taking  milk  only. 

I9th.— Slept  well  hist  night,  and  to-day  is  not  drowsy. 
Aakti  for  more  to  eat.  In  the  afteruoon  severe  headache 
came  on,  left-sided,  lanting  till  evening ;  patient  says  tho 
headache  she  has  of  late  suffered  from  ba»  always  been 


PDIBFERAL    ECLAKPSU. 


of  this  kind.  Polae  leas  froqn«nt.  Tongnc  dry.  Bowels 
open  five  times,  motions  ^een  and  very  offeosivo.  The 
©yea  were  examined  by  Mr.  Waren  Tiiy.  He  reports  that 
the  changes  are  singular  on  accoaut  of  the  largo  size  of 
the  white  patches,  their  semi-transparent  rather  than 
chalky  appearance,  and  the  email  nil tn her  of  Roialler 
glistening  patches  and  absence  of  sl-reaka ;  also  for  the 
sm&ll  number  of  haemorrhages,  of  which  there  are  only  a 
very  few  small  ones  iu  butli  eyes ;  the  white  patches  aro 
all  on  the  outer  sides  of  t!ie  diaca,  but  not  chioBy  in  the 
yellow  spot  regions  (where  there  are  only  a  very  few  emalt 
gliBtening  patches),  but  rather  distributed  down  and  ont, 
and  up  and  out,  from  either  disc. 

20th. — Bowels  open  six  times  sinte  yesterday ;  cha- 
racter of  mottoas  same.  Complained  of  occaeional  nbdo- 
xainal  pain  throughout  the  night,  less  daring  the  day. 
No  headftche  or  di-owsinesn  now.  Cough  and  lung  signs 
about  the  aaiue.  Skin  dry.  Pul»a  about  the  same. 
Takes  food  well.  Slight  tenclernesa  over  right  lower  ab« 
domen. 

Zlst. — Bowels  open  fivo  times  in  the  twenty-four  hours  j 
stools  no  longer  green,  but  brown  and  liquid.  Some 
griping  pain  in  abdomea.  No  headache,  slightly  drowayj 
in  morning. 

22nd. — No  more  abdomiual  pain.  Bowels  only  open 
once  ;  motions  brown  and  loose.  Pulse  112,  No  Tiead- 
Bche  or  drowsiness.  Her  progress  after  this  was  ontirclj 
satisfactory. 

80th, — Allowed  to  get  up. 

February   Hlh. — Vision  -3^;   reads  20  Jaeger.      Di»«. 
charged. 

Ikmjffrrnture. — The  teraperatare  at  8  p.m.  on  the  day 
of  admission  {the  patient  then  having  had  seven  fits,  the 
last  of  them  about  four  and  a  half  hours  previously}  was  99". 
At  a  p.m.  (the  pationt  having  in  the  interval  had  anothorj 
fit)  it  was  100  .  From  this  time  tho  temperature  wa»' 
taken  every  hoar  or  two  honrs  (according  to  circum- 
stances] until  the  end  of  tho  third  day.     Its  maximnm 


FOKKPEEUL    BCt-AMFSlA. 


93 


daring  the  stress  of  the  discBse,  100*6°,  was  roftclied  at 
0  p.m.  on  tlic  day  of  admission.  Then  it  sankj  reach- 
ing uoriunl  at  1  a.m.  During  the  whole  of  the  next 
day  it  dill  not  exceed  99'2*.  On  the  third  day  there 
vraa  a  rise  of  temperature,  liegionlng  at  0  a.m.  and 
reaching  a  maximum  of  lOl''!^  at  2  p.m.  Then  it  again 
fell,  and  at  midnight  was  DS'S".  There  wns  no  conspicu- 
ous change  in  paiient'a  condition  to  Recount  for  this  riso 
of  temperature.  After  thia  the  temperature  remained 
uormal. 

Urine. — As  far  as  possible  all  the  urine  excreted  was  ool- 
lectod.  The  catheter  wns  pns-ieil  on  adraiseion,  and  every 
two  honrs  subsequently.  Some  urine  tvas  passGd  into  the 
bed  in  the  iulervalH  ;  this  of  couree  could  not  by  measured, 
nor  could  that  which  was  passed  by  the  patient  along 
with  the  raotionti.  The  quantity  withdrawn  by  the  catheter, 
measured  and  shown  on  the  accompanying  chart,  is  there- 
fore less  than  the  total  quantity  excreted.  The  number  of 
motions  is  shown  on  the  chart,  so  that  an  idea  may  ba 
formed  of  the  amount  of  urine  which  escaped  meaeuro- 
ment  by  fwcompanying  them. 

Quantity. — During  the  first  twenty-four  hours  74e  ok. 
were  withdrawn  ;  in  the  seconil  twenty-four  hours  52  oa.  ; 
in  the  third  twenty-four  boui-s  it  reached  118  oz.  During 
the  sevenly-twi)  hoiira  which  followed  there  was  diarrhooa, 
and  thie  probably  accounts  in  part  for  the  diminution  in 
quantity  on  these  days  which  the  chart  ahowg.  Daring 
the  three  periods  of  twenty-four  hours  to  which  this 
applies,  08,  22,  and  22  ox.  wcru  the  qnantitiuti  withdrawn. 
Then  the  chart  shows  a  gradual  increase  in  quantity  each 
day,  till  on  the  eleventh  period  of  twenty-four  hours, 
86  oz.  were  collected.  Duriug  the  remaining  four  days 
in  which  the  urine  was  measured  the  daily  quantity  was 
from  56  to  GO  oz. 

The  quantity  of  urine  was  thus  throughout,  if  allowance 
be  mude  for  nnaroidable  incompleteness  of  collection, 
above  the  average  of  health.  This  ioorcase  in  the  quantity 
passed  was  present  during  the  height  of  the  disease,  while 

VOL.  xxxn.  3 


FtTEBPBBAL  ECUUIPSU. 


the  patient  was  having  the  fita.  Delivery  was  followed 
hy  temporarily  increased  diuresis. 

Specific  gravitij. — As  might  have  been  expected  from 
the  increased  amount  of  urine,  its  specific  gravity  was  low. 
It  was  especially  low  while  the  patient  was  having  fit-s. 
That  of  the  urine  drawn  off  at  tho  time  o£  admission  and 
Bubsequentty  up  to  4  p.m.  [tlie  last  fit  heing  between  + 
and  5)  was  only  1007.  At  C  p.m.  the  specific  gravitj'  of 
the  nrine  tad  risen  to  1010,  and  at  9  p.m.  to  1012.  Thus 
increase  in  the  density  of  the  nrine  coincided  with  cessa.- 
tion  of  the  fits.  The  dimtnut-ion  of  the  ijuantity  of  urine 
on  the  fourth,  fifth,  and  sixth  days,  which  the  tabic  shows, 
although  DO  doubt  partly  accounted  for  by  mach  of  the 
urine  Laving*  been  lost  with  the  etools,  yet  woald  eoem 
partly  due  to  greater  concentration  of  the  urine  j  for  at 
the  satne  time  there  was  a  rise  in  the  specific  gravity, 
which  reached  its  luaxiunim^  lOH,  on  the  fifth  day.  This 
KpBcifie  gravity  was  again  reached  on  the  seventh  day,  tho 
tiimntity  of  urine  passed  on  that  day,  exclusive  of  that  lost 
with  oui>  action  of  the  bowels,  being  only  36  uz.  After 
that  the  specific  gravity  stood  at  1012  or  lower  throughout 
the  patient's  stay  in  hospital.  The  specific  gravity  was 
thus  below  the  average  of  health  much  in  proportion  as 
the  quButity  of  urine  was  above  that  average. 

Alhmnen. — The  amount  of  albumen  present  in  the  urino 
WM  measured  by  precipitating  it  with  boat  and  nitrio  acid, 
letting  tho  nrine  stand,  and  then  roughly  measuring  the 
amount  of  precipitate  by  the  eye.  The  nrine  drawn  off 
on  admissiou  gave  a  precipitate  of  quite  half  ite  bulk  of 
albumen.  The  next  specimen,  drawn  off  at  2  p.m.,  did  not 
contain  quite  so  much — about  three  eighths  of  its  bulk. 
That  drawn  off  at  4  p.m.  contained  still  lessji — about  one 
third.  Hetwecn  4  and  h  the  patient  had  a  fit,  and  the  nrine 
drawn  off  at  0  p.m.  contained  two  thirds  albumen,  and  that 
at  7.20  p.m.  three  quarters  [dbumi-n.  Thisincreanu  in  the 
amount  of  albumou  following  a  fit  is  noteworthy.  There 
waa  not  quito  so  much  in  the  urino  drawn  off  at  9  p.m., 
about  one  half;  and  in  that  at  10.40  p.m.  (shortly  before 


TVBBPEIUL   BCLAHPSU. 


35 


delivery)  two  thirels.      At  1  a.m. — that  is,  after  delivery- 
it  had  sunk  to  one  third.      It  tbeo  went  on  dimimshing 
till,  at  2  p.m.  the  ucxt  day,  tbci-e  was  only  oue  sixth. 
Aft«r  this  the  amount  again  iocreesed  a  little,  and  tLrougU- 
out  the  rest  of  the  patient's  stay  in  hospital  the  nrino  coix- 
taioed  from  n  quarter  to  a  lliird  of  its  bulk  of  albumen. 
Specimen!?  of  orine  were  from  time  to  timo  tested  to 
•  •■certain  the  proportion  iv  wliicli  the  iilhumen  was  uom- 
^poeed   of  parnglobiilin   and    serum   tilhiimen   respHCtlvely. 
The  specimens  passed  on  the  day  of  admission  showed,  on 
treatment  with  sulphate  of  mag-uesia,  a  considerable  Ioosr, 
flaky  procipitAte  tif  paraglobiilin,  amounting,  when    the 
nrine  hftd  been  allowed  to  stand,  to  about  one  third  of  its 
balk.      After  separating  the  paraglobuHn  by  filtration  and 
treaticj^  the  Sltered  fluid  by  boiling  and  nitri«  acid,  there 
was  still  an  afjundant  preoipitate.      Specimens  drawn  off 
at  7  a.m.   and  at  6  p.m.  on  the  day  following  admission 
(and    delivery)    «lio»Ted,  on    treatment  with   sulphate  of 
lagnesia,  only  a  small  flaky  precipitate,  too  small  to  bo 
F<atimatcd  by  bulk,      A  similar  small  precipitate  was  ob- 
'ieined  From  nrino  passed  on  Jammry  18bh  nud  19th.      On 
January  2Ist  (the  5ixth  day]  the  tiuantity  of  paraglobulja 
had    Blink    to  n  mere  trace,  and  this  trace  was  present 
throughout  the  rust  of  the  patient's  stay  in  hospital. 

Depotii. — The  first  two  specimens  of  uriji©  contained 

■  Tory  little,  if  any,  doposit.      In  alt  the  sabsequent  speci- 

nena  there  was  a  flaky  white  deposit,  oxcopt  ou  the  second 

and  (bird  daya,  when  the  depuBit  was  rud^  probably  due  to 

I  a  Blight  admixture  of  blood,   possibly  produoud  by  the 

'frequent  use  of  the  catheter.      MIcro.scopically  the  deposit 

thronghoQt  consisted  of  abundant  gi'anular  casts  and  uric 

aoid  crystals. 

Urtn. — Ou  admission — that  is,  while  the  fits  were  recur- 
ring— although  the  quantity  of  urine  was  above  tha  average, 
the  amount  of  urea  elimiuiitcd  in  it  was  much  below  tlio 
average  ;  not  only  below  the  average  of  health,  but  below 
the  amount  that  one  would  have  expected  to  find  iu  urine 
of  that  specific  gm\nty.     During  the  first  twenty-four 


$6 


PDIRPSBAL  ZOUJit^i 


bonra  only  168  grains  of  urea  were  foond  to  have  been 
excreted  j  in  the  second  twenty- four  hours  183  grains. 
Then  the  chart  shows  that  tie  urea-exeretion  ran  np  to 
ite  uormal  quantity,  484  grains  being  elimiuated  in  the 
third  twenty-four  hours.  After  this  the  curvB  showing 
the  urine  quantity  tind  that  of  the  urea  quantity  run  close 
to  one  ftuother,  while  on  admission  the  urea  curve  is  far 
below  the  urine  curve.  The  hourli/  variaiian  of  the  nrcji. 
percentage  is  ah  own  on  the  same  chart  as  the  hourly  tempe- 
rature. On  admission  it  waa  only  "3  per  cent.,  and  it  re- 
maiued  at  tliig  until  after  the  last  iib  had  ocouned.  Thou 
it  immediately  bega.n  to  rise,  and  rose  with  tolcroblo 
pagularity,  till  twenty-eight  hours  after  delivery,  i.  e. 
thirty-sis  hours  after  the  last  fit.  Delivery  does  not  seem 
to  go  wllh  any  marked  change  in  the  urea  curve. 

Swyar. — Tlie  urine  was  many  times  examined  for  eugar, 
but  none  was  found. 

Bendion. — Its  reaction  was  acid  thronghout. 

February  19th,  1889. — Patient  came  back  to  report 
herself.  Urine  pale,  acid,  up,  gr.  1011  ;  urea  I'l  per 
cent.  ;  proportion  of  eno  fifth  albumen  ^  uo  paraglobuUu ; 
no  sugar. 

August  3rd,  1889. — Patient  looking  well,  not  ansemic. 
Thinks  herself  well,  except  that  sight  ia  imperfect.  Urine 
containing  one  third  albumen. 

In  this  cascj  although  rise  of  temperature  followed  the 
fits,  it  did  not  follow  so  itmnediately  as  to  favour  the 
view  that  it  was  directly  au  effect  of  the  fits.  The  case  is 
remarkable  and  exceptional  in  that  the  quantity  of  urine 
waa  increased  instead  of  diminished. 

The  cessation  of  the  fits  was  followed  by  immediate  in- 
creaee  in  tht)  percentage  of  urea,  in  the  nrino ;  hut  restora- 
tion of  the  urea  excretion  to  the  normal  amount  was  not 
complete  till  twenty-four  hours  or  more  after  the  cesHation 
of  the  tits. 


87 

Cask  3. — Pritnigmvida  ;  ■premonitory  nymptoms  forty -eight 
hours  before  omef  of  Jits  at  Jive  months'  pregnancy; 
about  ^ieen  fits  i  sponianfonf  pr*;pintiiTe  lahour  ;  cea- 
imtif/n  of  ft' ;  fall  of  te7n2>emf.urp.  nn.d  diminution  of 
alhumiauria  foUowiiifj  ndministratimi  nf  morphia  ani 
ynetding  efsHvery  ;  diminution  of  urine  and  of  urea- 
excTtiion  (both  abmlute  und  in,  proportion  to  the  urtfie)' 
during  fits  ;  partial  re~cslabliahmcnt  of  urine  and  «rf;ra- 
eacreiion  after  cessation  of  fits  and  before,  deliicrij ; 
fuine  solid  with  albumen,  lartjeltj  parntjlnbulin.  (Ke- 
ported  hy  Dr.  U.  G-.  LySj  Resident  AccoucKeur.) 

M.  G — ,  ftgod  20,  admittod  into  tho  London  HoBpital 
Maroh  3i-d,  1889. 

Patient  had  always  previously  had  good  health.  No 
fits.  Sh«  was  married  eleven  raonths  ago,  and  miscarried 
two  months  aftrr  marriage.  She  now  thialcs  herself  about 
BIX  montba  pregnimt. 

Aboot  7.30  a.m.  on  March  Ist  aho  began  to  complain 
of  beftdacho  and  paia  in  tho  lower  abdomen.  On  March 
2nd  her  eyelida  woro  nuticod  to  be  swollen,  her  headache 
vraa  worse,  and  sho  had  much  pain  in  the  lower  abdomen 
Rod  loios.  About  10.30  p.m.  on  chat  evening  she  began 
kto  feel  siclc.  On  Maruh  3rd  at  3  a.m.  she  began  to  vomit, 
'fend  vomited  on  and  off  till  9  a.m.  At  9  a.m.  she  had  a 
fit.  During  the  day  other  fits  recurred,  the  patient  being 
said  to  have  had  about  a  do/.en.  She  was  reported  to 
hare  passed  a  good  deal  of  water  into  the  bed  since  the 
fits  began. 

She  was  admitted  at  S.45  p.m.  At  4,  4-.30,  and  5  p.m. 
she  bad  epileptiform  seizures.  Each  fit  was  preceded  by 
theavy  breathing  for  about  five  minulea,  aud  began  by 
twitching  of  the  thumbs,  which  was  succeeded  by  general 
clonic  spasms.  Strong  contraction  of  the  ntorns  was 
noticed  during  tho  fits. 

At  5.15  p.iii.  half  a  grain  of  morphia  wan  given  hypo- 
'  demiically. 

At  6.30  p.m.  the  following  note  was  made : — Pntient 


FTEIIPKSAl   CCLAVT8IA. 


lying  fjiJiot,  l)«t  constantly  groaning.  Pulse  88,  full  and 
bard.  Patient  fiorid  a»  to  complexion  and  niQCons  mem- 
branes. No  mnrked  ccdema  of  face  ;  slight  oedema  of 
legs.  Cardiac  duluess  bonnded  ou  tho  left  by  nipple  bne. 
Nn  murmnr;  no  ubuormol  sounds  over  lungs.  Hepatic 
dulnexs  not  incruaticd.  Spleen  not  felt.  Fundus  uteri  a 
finger's  breadth  below  the  umbilicus.  Pains  occurring 
every  quarter  of  an  hour  or  oftencp.  Oa  uteri  jii8t  admits 
finger;  cervical  caual  not  obliterated. 

7.55  p.m.,  another  lit,  chiefly  right  Bided,  beginning  in 
right  thumb  and  extending  up  arm  to  trunlt ;  lasting  three 
miuutes.  10  p.m.,  patient  very  restless,  but  has  had  no 
more  fits.  Condition  of  utenis  mucli  the  snme.  Morphia 
gr.  ^,  and  iitropiii  gr.  a'^^,  given  snbcutaueously. 

March  4tb,  7  a.m. — Very  restless.  Slept  on  und  off 
thronghout  night ;  struggling  wlion  the  catbotor  was 
paBBed,  end  also  waking  at  frequent  intorvals  without  this 
oaase.  8.45  a.m.,  cervical  canal  obliterated  ;  oa  externum 
the  bIko  of  a  shilling.  9  a.ia.,  morphift  gr.  jt,  atropin 
gr.  ^,  given  subcutaneously.  10  a. in.,  fcotue,  of  about 
five  months'  gestation,  expelled.  Chloroform  given  during 
removal  of  placenta  ajid  douche.  10  p.m.,  patient  has 
slept  all  day  except  when  touched.  In  latter  part  uf  day 
has  taken  plenty  of  milk.  To-night  is  more  rational  and 
lees  violent;  knew  her  mother. 

15th. — ConvftloBcenoe  lias  been  uninterrupted  since  last 
note.      No  more  fits.      Now  gets  up,  and  icAa  quite  well. 

Temperature. — Ou  admission  the  toinpcrature  was  101*. 
At  5  p.m.,  the  patient  having  had  throe  fits,  it  had  risen 
to  102'4* ;  then  it  began  to  fall,  and  continued  to  do  bo, 
although  about  8  p.m.  the  patient  had  a  fit,  till  10  p.m., 
when  temperature  was  lOO".  At  the  time  of  the  In.'it  fit, 
8  p.m.,  the  tempornturp  was  lOl",  and  an  hour  afterwards 
101'4'^.  Between  midnight  and  2  a.m.  the  temperature 
rose  to  102'3",  without  further  fits  or  any  marked  coincident 
change  in  the  patient's  condition.  After  2  a.tn.  it  r&pidly 
fell)  reaching  normal  by  8  a.m.  After  this,  throughout 
the  patient's  etay  in  hospital,  it  never  exceeded  100°. 


PUEBPEBAI  ICIAUPStA. 


Vrine.  Qumility. — During  the  first  forty-piglit  Boors  tlhe 
catlieterwas  passed  overy  two  houi-s,  and  tlie  urine  measured. 
But  little  if  any  was  passed  into  the  bed.  The  amoiintB 
recorded  represent  the  actual  excretion  as  accurately  as 
is  possible  in  the  cnse  of  n  female  patient.  T!ie 
chart  bIiows  a  great  diraioutloQ  in  the  quantity  of  urine 
during  the  period  of  recurrence  of  the  fits,  a  slight  in- 
crease in  quantity  during  the  period  from  the  ceseation 
of  tho  fits  until  delivery,  and  a  oonaidemble  and  rapid 
rise  in  tho  quantity  of  urine  after  delivery.  From  4.  to 
fi  p.ui.,  that  iSj  from  adtnisHioii  till  the  ceaaation  of  the 
fits,  the  average  amount  of  urine  was  about  half  an  ounce 
per  hour.  From  9  p.m.  till  10  a.m.,  the  time  «f  delivery, 
it  averaged  not  quite  three  quarters  of  an  ounce  per  hour. 
During  the  twenty-three  hours  following-  delivery  it 
averaged  about  2  oz.  per  hour,  During  tlio  first  forty- 
eight  hours  the  measurement  and  esnmination  of  the 
urine  were  carried  out  under  the  immediate  superviaiou 
of  the  Itesident  Accoucheur,  Pr.  H.  G.  Lys ;  and  I 
believe  that  the  figures  given  are  as  accurate  as  they 
conid  be  made.  After  thia  time,  other  duties  prevented 
hJ8  giving  such  close  attention  to  this  cnse;  and  al- 
though instructions  were  givon  that  all  the  urine  should 
be  Kaved,  the  Bmalt  amount  collected  makes  it  seem 
donbtful  whether  or  not  this  was  faithfully  done.  But 
the  smallness  of  the  amount  whs  noticed  at  the  time, 
and  every  care  taken  to  impress  upon  the  patient  and 
nurses  the  importance  of  saving  the  whole  of  the  urine. 
Borne  was  of  course  lost  when  the  bowels  acted,  and  tho 
number  of  motions  is  shoivn  on  the  chare.  I  bolicvc  that 
the  facta  are  recorded  as  accurately  as  they  could  be  in  a 
female  patient.  The  quantity  of  uriuo  which  was  collected, 
and  which  is  shown  in  the  chart,  is  considerably  below  tho 
average  of  health. 

8f«eifit  gravity. — Unfortunately  I  have  no  record  of 
the  specific  gravity  before  deliver}'.  Its  variations  after* 
wards  do  not  permit  any  iuferenc*  to  be  drawu  from  them. 

^Wumen.—Ou  admission,  the  urine  contained  so  mach 


4S 


PUEBPEB&L    ECLAUPaU. 


ftlbainen  tbat  on  lioiliog  it  became  eolid.  That  drawn  off 
at  9  p.m.  (the  last  Bt  haviQitr  occurred  an  hour  l)c£oro) 
only  contained  half  its  bulk  of  albumen.  At  1  n.m.  tLo 
qnaotity  of  albumen  hod  sunk  to  one  fonrtb.  The  urins 
continued  to  contain  about  thia  (juautity  till  the  spocimoa 
withdrawn  five  hours  after  deHvery,  which  only  contained 
one  sixth.  Nineteen  hours  after  delivery  there  was  only 
one  twelfth  of  albumen  in  the  iiriue,  and  the  next  day 
only  a  trace.  A  small  quantity,  about  one  fifteenth,  waa 
still  present  when  the  patient  left  the  hoepital.  The  alba- 
ntiuous  precipitate,  which  on  admission  rendered  the  urine 
solid  when  boiled,  was  largely  composed  of  paraglobuHu. 
Thia,  when  aeparately  pracipitated,  amounted  to  about 
half  tho  bulk  of  the  nriuo.  When  next  examined,  five 
hours  after  ths  la^t  fit,  the  albuminous  precipitate  having 
then  sunk  to  a  quarter,  there  waa  only  a  traes  of  para- 
globulin  present.  The  nrine  was  afterwards  frequently 
examined  for  paraglobulin,  but  either  uoiie,  or  only  a 
trace,  waa  present. 

Frea.— This  was  estimated  by  Russell  and  West's  hypo- 
bronaate  process.  The  results  (stated  on  the  chart)  show 
during  the  period  of  the  fits  a  diminution  both  in  the  tola] 
urea  excreted,  and  also  in  the  percentage  of  urea  contained 
in  the  urine.  Trom  admission  till  Q  p.m.,  that  is  during 
the  period  of  the  fits,  the  percentage  of  nrea  was  '84,  and 
the  arerBge  anionut  of  urea  excreted  per  hour  was  l'62i 
grains.  This  rate,  if  continued  for  twenty-four  houra,woQlcl * 
give  about  30  grains  as  the  daily  excretion.  From  the 
cessation  of  the  fits  till  delivery  the  avernge  percentage 
was  1'24  grains,  and  the  average  hourly  excretion  4'42 
grains,  a  rate  which  would  give  about  106  grains  as  tbe 
daily  excretion. 

It  will  be  seen  from  the  chart  that  there  were  great 
differences  in  the  percentages  of  urea  from  hour  to  hour. 
I  BUI  unable  to  offer  any  explanation  of  these  variations. 
They  60  struck  Dr.  Lys,  that  he  frequently  twice  estimated 
the  nrea  in  the  same  specimen,  that  he  might  OToid  acci- 
dental error.     Dr.  Kingston  Fox  has  published  some  obser* 


IJtkl  KCLittrsU. 


43 


ratioBB  vhich  go  to  eKow  th&t  in  tiealtb  the  amount  of 
orea  excreted  per  hoar  is  a  tolerably  conetaut  quantity, 
both  during  night  and  day,  while  sleeping  and  vraking, 
whether  the  urine  bo  ropions  or  scmity.  If  this  ho  ao, 
tLa  BnotaatiouK  in  this  cnso  would  seem  a  feature-  duo  to 
the  morbid  oondition  of  tlio  kidneys. 

DeposU.—'Tho  urine  withdrnwu  on  admUsion  gave  on 
cooling  a  deposit  of  lithates.  This  was  present  in  roost  of 
the  Kpccimons  examined  until  after  delivery,  when  uric 
acid  ciystals  were  found  as  well.  After  delivery,  casts 
were  aonitht  for  with  care,  but  not  found.  The  urine 
before  delivery  was  so  &caDty,  and  eo  niuob  of  it  wm  uaed 
up  in  estimatiiig  the  urea,  that  little  w&s  loft  for  micros- 
copical parpoacs. 

Sugar.— On  March  9th,  lOth^  and  llth  the  urine  con- 
tained a  trace  of  sugar.  This  was  probably  galactosuria. 
There  was  no  sugar  present  at  any  other  time. 

This  case  dues  nut  HUpport  the  view  that  the  rise  of 
temperature  is  an  effoct  of  the  fits,  for  after  three  fits  had 
oooarred  in  rapid  succession  the  tempcTatnro  began  to  fuJl, 
and  oontinned  to  do  so  in  spite  of  the  occurrence  of 
another  fit.  TIio  quantity  of  urine  during  the  fitx  was 
diminished,  but  only  a  partial  rc-estnbliabment.  of  the 
excretion  accompanied  the  cessation  of  fits;  more  com- 
plete reHtoration  followed  delivery.  In  this  respect,  that 
only  a  partial  re-itoratinn  of  renal  function  apparently 
enilioea  to  stop  the  tendency  to  fits,  the  case  is  like  the 
two  preceding  ones. 

I  ha¥e  tried  to  trace  the  subsequent  bistory  of  tbis 
patient,  but  have  failed  to  do  so. 


Cask  4.— -Teaifc  pregnancy  ;  »yvij>loms  a  week  hefore  fiit  at 
$evBn  monthe'  pregnancy  ;  three  dayn'  treatmani  by  milk 
diet  in  hofpitnl  hoforc  fitfi  ,-  relimtif  ;  four  /tie  only  ; 
morphia  given  after  second  Jit  ;  death  hy  coma  Jive  hours 
after  lasljii  ;  tuhnormal  temperature ;  fit preecdid  and 
aceompanitd  hy  diureitis  ;    albwminuria  diminithed  hy 


44  FUBRFBRAL    ECLANPSU. 

rest  and  milk  diet ;  Jtl"  accompanied  and  foUou'ed  by 
infrfane  of  albuminuria  tind  hematuria;  steady  dimi- 
nution  in  vrea'purceninijfi.  2>'>'''-ceding  jUs  and  rontinmug 
till  ilmth  ;  ahuolute  ftiaittiltj  nf  urea-excretion  drmi- 
■ni^hi'd,  hut  no  grenter  diminution  jtrecedtng  ur  accom- 
panying Jits.  (Reported  by  Dr.  H.  G.  Lys,  Resident 
Accoucheur,  and  Mr.  W.  C.  Atlwabd,  Clinical  Clerk.) 

L,  M — >  agsd  37,  admitted  iuto  the  London  Hoepitat 
March  2ist,  1889. 

Family  ht^tonj. — Father  died  from  "  feroncliitis,"  oged 
fifty-six;  mother  from  "bronchitis  and  dropsy,"  aged 
forty-four ;  one  brother  was  found  dead  in  bed,  agod  thirty- 
two,  canse  of  death  said  to  be  "asthma  and  brouohitis ;" 
oneaister  died,  aged  twcmty-soveu,  of  "  consumption."  Two 
of  patient's  children  died  from  ^'couviilsions,'*  one  from 
"bronchitis,"  and  one  from  "consumption." 

Persmial  hinttiry. — Until  this  iiJness  patient  said  that  she 
had  had  good  health.  She  had  had  smallpox  when  aged 
three  months,  aiitl  scarlet  fuvt-r  when  aged  nine.  She 
began  to  menstruate  at  fourteta,  aod  was  always  regular, 
except  during  pregnaucios.  She  waa  married  ot  twenty- 
one,  and  had  had  eight  childron  and  one  miscarriage.  All 
the  children  were  bom  at  term,  living  and  healthy.  The 
labours  were  easy.  In  1881,  about  two  or  three  months 
after  the  birth  of  the  sixth  child,  she  had  n  "  tnniour  *'  in 
the  left  side.  She  came  to  the  hospital,  was  Admitted^ 
And  while  in  hospital  the  tumour  "  dispersed.''' 

Patient  coneidcrs  herself  seven  mouths  preg'naut.      She 
complains  of  sllg-ht  cough   and  shortness  of  breath ;   but 
chiefly  of  dimness  of  sight.      This  came  on  four  days  ago> 
and  has  been  getting  worse  since.      It  seemed  at  first  ns, 
if  there  were  a  film  over  her  eyes,  and  now  everythiuf 
looks  hazy. 

The  patient  on  admission  was  somewhat  nniemic.      The 
enlarged  utenis  reached  between  three  and  four  inches 
above  tbe  umbilicus.     The  foetal  heart  was  audible.     There  | 
was  slight  cedema  of  legs  and  feet,   but  none  above  the 


POBBPRRAL   ECLAMPSIA. 


45 


;  tione  ot  face  j  no  ascites.  No  abnormal  signs  over 
houri  or  luugs. 

Ophthalmoscopic  Citaminatton. — Right  eye  :  inner  part  o£ 
disc  swoUoa  and  margin  lost,  outer  part  wliite  and  not 
apparently  swuUyn  ;  duwuwarda  and  outwards  from  tha 
disc  an  irreg'iilar  white  patch;  signs  u£  other  sucli  patches 
commencing,  and  small  hfemon'hages  id  outer  part  of  field. 
Left  eye  :  disc  similar  in  appeiirauce  to  right,  cominenc- 
ing  white  patches  in  onter  part  of  field,  and  much  larger 
patches  of  hBamonliage  than  in  right  eye. 

Temperature  was  uormal,  aud  uriue  contained  one 
quarter  of  its  bulk  in  albumen. 

The  pationt  was  put  upon  milk  diet,  kept  in  bed,  given 
Ferri  Amm.  Oit.  gi'.  v,  three  times  a  day,  and  instructions 
were  gizen  that  all  tha  urine  passed  Bhoald  be  saved  for 
meaanroniDnt  and  examination. 

March  2ith. — Patient  complained  last  night  of  pain  in 
chest,  and  did  not  sleep  dnrlng  the  night.  At  5  a.ni.  she 
had  a  fit;  at  7  a.m.  another  fit.  Between  the  two  lita 
and  after  the  second  fit  she  completely  regained  conscious* 
ness.  Half  a  grain  of  morphia  was  given  after  the  second 
fit.  This  was  followed  by  sleep,  which  gradually  deepened 
into  coma.  The  pativut  hud  a  third  ht  at  D  a.m.,  and  a 
fourth  at  10  a.m. — a  very  long  one,  attended  with  extreme 
lividity.  The  breathing  after  tliis  gradually  became 
heavier  and  slower,  the  pulse  smaller  and  weaker,  and  the 
patient  died  at  8  p.m. 

No  antopsy  was  permitted. 

'i'einpi^raturc. — The  heat  of  the  body  never  exceeded 
normal.  It  was  normal  on  admission,  and  on  the  morning 
and  evening  of  the  23rd  (the  day  after  the  litx).  It  was 
taken  at  7  a.m.  and  aguin  at  0  a.m.  on  the  24th,  but  the 
thermometer  did  not  rise  above  56'^. 

Urine;  quantity. — It  has  been  mentioned  that  instruc- 
tions wore  given  that  all  the  uriue  pattaed  by  the  patient 
should  be  saved.  The  boweb  acted  twice  on  the  23rd  (the 
day  before  the  fits),  so  that  on  this  day  some  urine  was 
loftt.     From  the  time  of  admission  till  S  a-m.  on  the  22nd 


46 


rUBRrCltAL    BCLAHPSIA. 


40osc.  of  uvine  were  passed.  From  8  n.m.  on  the  22nd 
to  8  a.m.  oil  tlie  23rdj  only  24  oz.  From  8  o.m.  to  8  p.m. 
on  tho  2'StS,  21  oz.  From  8  p.m.  on  the  23rd  to  8  a.m. 
on  the  24th — that  is,  during  the  twolvtt  hours,  in  the  latter 
three  o(  which  the  fits  came  on,  38  oz.  The  fits  were 
therefore  not  preceded  by  any  diminution  in  the  (juantity 
of  urino,  but  rathor  hy  nn  augniBntatJon.  On  the  2'lth 
the  cnthoter  was  agnin  poBsed  at  9  nud  1 1  n.m.  and  at 
2  p.m.,  and  in  r11  16\  oz.  were  withdrawn.  Thi.s  rate  of 
oxcrelion,  continued  for  twentj-Four  hours,  wonld  give  06 
OS.  of  urine.  The  fits  in  this  case  were  therefore  preceded 
and  ac'compunied  rather  hy  diuresis  than  hy  diminution  in 
the  amount  oi  urine. 

Specijie  ■gravity. — This  ranged  from  1010  to  1015.  It 
was  LOlO  on  the  day  of  admission ;  on  March  2drd  1012. 
That  of  the  38  cz.  passed  in  the  twelve  hours  endinif 
March  24th  8  a.m.  was  1010.  The  specific  gravity  of  tho  . 
urino  drawn  off  at  ft  a.m.  was  1015;  that  of  the  nrine  a-ti 
2  p.m.  1014.  Tho  disease  does  not  thoroforc  appear  to 
have  been  attendod  n'ith  any  diminution  in  the  excretion 
of  urinary  solids. 

Alhumni. — When  patient  was  admitted  the  urine  con- 
tained one  quarter  of  its  bulk  of  albumen.  Its  quantity  was 
estimated  roughly  by  the  eye  after  precipitation  and 
skanding.  Tlio  day  afLi-r  admission  tho  quantity  had  snnk 
to  one  tenth,  and  on  tho  23rd,  the  day  before  the  fits,  to 
one  twelfth.  Tho  nrine  of  the  twelve  hours  ending  S  a.m.> 
March  ^-tth  (fits  in  the  last  three  hours  of  those  twelre), 
contained  one  third  of  its  bnik  of  nlbnmen  ;  and  that  drawn 
off  nt  9  a.m.  and  1 1  a.m.  was  almost  solid  with  albumen. 
That  withdrawn  tit  2  p.m.  contained  Gve  sixths  of  ite  bulk 
of  albumen.  The  nrine  paased  on  the  23rd  (before  the 
6ts)  was  examined  for  paraglobulin,  and  this  was  found 
present,  bnt  unfortunately  no  not©  has  been  preserved  as 
to  its  quantity,  and  the  urino  was  not  a^in  tested  for  it. 

Id  this  case  it  will  be  soeii  that  diminution  in  the  amount 
of  albumen  followed  treatment  by  rest  and  milk  diet,  and 
that  the  lits  were  accompanied  and  followed  by  great  in- 


PXTEBFSBAL  ECLAHrSU. 


47 


CTC«80  m  the  Bmoont  of  olbnmeo.  Thero  is  no  evidonee 
whothcr  or  not  ttio  fits  wore  immedintBly  preceded  by  an 
increase  in  thu  auount  of  albumen ;  but  uo  sach  increase 
loDff  preceded  tHem. 

Urea. — The  percentage  of  urea  was  estimated  by  the 
hypobroiDBte  process  o(  Itui-sell  and  West.  The  percen- 
tage was  thronghoat.  below  the  average,  and  below  wbat 
would  have  been  expected  from  tbe  specific  gravity  of  the 
urico.  On  admission,  tbe  percentage  was  '7.  On  tlie  day 
foilowiog  it  baa  risen  to  "f .  Next  day  daring  the  twelve 
boors  before  that  in  wbich  the  lUa  occurrod,  it  fell  to  '8. 
Then  it  went  on  steadily  diminishing  until  death.  The 
urine  passed  duritjg  the  twelve  hours,  in  tho  latter  threu 
itt  which  the  fits  occurred,  contained  'G  per  cent,  uf  ucRn, 
That  drawn  off  at  9  a.m.  contained  tho  same.  The  speoi- 
men  obtained  at  11  n-m.  only  showed  -5  per  cent.  ;  and 
in  the  urine  withdrawn  at  2  p.m.  (an  hour  before  death) 
Ihoro  Yvas  only  "4  per  cent.  But  although  the  percentage 
of  urea  thus  sicaclily  iliminishcd,  tht*  total  excretion  of 
nrea,  although  much  below  the  average  of  bealth,  did  not^ 
during  the  period  of  the  6t9,  fall  below  the  average  of  tho 
preceding  days.  In  the  Iwcnty-fonr  hours  following  ad- 
TDi38ion  154  grains  were  excreted  ;  in  the  second  twcnly- 
foar  hoars  103  grains  ;  in  the  third  twenty-four  hours 
(in  the  last  throe  hours  of  which  tho  fits  occurred)  21S 
grains  ;  and  in  the  six  hours  ending  an  hour  before  death 
30  grains,  a  i-ate  of  which,  if  kept  up,  would  give  an 
amount  for  the  twenty-four  hours  of  156  graina. 

Deposit. — In  the  first  few  days  the  urine  was  clear, 
giving  no  deposit.  The  urine  passed  between  S  a.m.  and 
8  p.m.  on  March  2Jird  was  reddish  in  colour,  and  gave  a 
deposit  of  blood.  Between  B  p.m.  on  March  23rd  and 
8  a.m.  on  March  24th,  it  was  port-wino  coloured,  with  a 
deposit  of  blood  and  casts.  The  subsequent  specimens 
wore  black,  liko  porter,  and  gavo  a  deposit  of  blood  discs, 
granular  and  epitbcltnl  cast?.  In  the  last  specimen,  ob- 
tained an  hour  before  death,  there  woro  aUo  orates. 

The  reaction  wan  acid  throughout. 


48 


PUBBPSIUI.   ECLAKPSU, 


No  augar  was  present. 

This  case  ia  remarkable,  in  ttiat  the  temperature  was 
uever  aboro  uorcnal,  aud  sank  to  Bubnormiil  before  death. 
Tlioee  wLo  regard  puerperal  convulsions  ns  beiug  BoraQ- 
thing  different  to  ordinary  arteiiiic  couvulsiouM  would  per- 
haps regard  ttiis  case  as  one  oC  urtemia,  not  of  true 
eclampsia.  But  there  was  no  history  pointing  to  chronic 
kidney  diaeasp,  nor  did  the  symptoms  resemble  those  of 
ordinary  acute  nephritis.  The  fits  were  neither  preceded 
uor  accompanied  by  diminution  in  the  quantity  of  nrine, 
uor  by  any  grcftter  deficiency  in  the  osoretion  of  urea  than 
had  been  present  at  u  time  when  the  patient  did  not  pre- 
sent  grave  aymptoma.  The  only  explnnation  that  I  can 
suggest  IK  that  a  persistent  deficiency,  even  though  not 
great,  in  the  excreting  power  of  the  kidneySj  may  hare 
led  to  cumulative  retention  of  urea  in  ihebleod  and  tiasues 
which  at  length  reached  the  point  of  exeit,ing  convulsioua. 
I  refrain  from  offering  any  argument  on  the  question  »b  to 
whetht'^r  it  he  urea,  the  uou-excretion  of  which  is  really 
the  important  factor  of  so-called  Hr[eraic  seiauree.  These 
cases  do  not  eeera  to  mc  to  afford  a  basis  for  the  discusaion 
of  that  question.  Another  important  point  also  arises  oat 
of  this  cnacj  viz.  whether  the  morphia  contributed  to  the 
fatal  termination.  The  patient's  condition  was  worse 
after  the  morphia  than  before  it.  The  evidence  (of  which 
the  other  cases  related  in  this  paper  form  part)  that  in 
many  caees  of  puerperal  eclampsia  the  use  of  morphia  is 
followed  by  a  favourable  termination  is  now  so  abundant 
that  I  do  not  infer,  from  the  clinical  history  of  this  case, 
that  the  morphia  was  injurious.  It  may  be  that  there  is 
a  claaa  of  cases,  to  which  this  one  belouga,  in  which  mor- 
phia is  harmful.  Further  researcli  is  needed  to  show  thla, 
audj  i£  there  be  such  a  claes^  to  define  its  characters. 


Cabs  5. — Primigravula  ;  symptoms  nlout  thirty-six  hourit 
heforc  JitSf  at  eight  noJitht'  pre^nmicy ;  intra-vterine 
death  oj'fa'lus  ;   twenty-four  jits  in  ail,  extending  «ver 


ITKBrElSAL.    ECLAUralA. 


49 


mrly  hours,  and  cramng  he/ore  ifeHrerjj  ;  iJr.Hrium  for 
foHy-eirjhl  hmirs  after  fits  ;  flhjht  pyreMit,  eubindiiig 
before  ccpxfttion  of  Jits ;  duri)i<j  tints  of  anrltor  Jits  urine 
/rt/lui  tcilh  iilhiimen  ami  dhiinisfied  in  quccntity,  but 
pertentage  of  urea  not  diminished  ;  increttsc  in  qvnntily 
vf  ttrine  and  percentage  of  urea,  and  diminuUon  of 
alhuminnria  h^fore  vensaliun  of  fits,  (Roportod  Vy  Dr. 
F.  Howard  Tajlob,  Resident  Accouclieur,  and  Mr.  W. 
DtilOAN,  Clinical  Cleric.) 

S.  S — ,  DKcd  3-^,  admitt;«d  iuto  bhe  London  Hospitalj 
May  2iat,  1889. 

Family  hi-nionj. — Fnthor  died  suddenly  of  licnrt  discftsc, 
aged  49 ;  mother,  of  asthma,  aged  44.  No  history  of 
iusauity  iu  &Dy  relative. 

PrwiouH  history. — Pntlont  first  tneusli'iiati'd  at  BixtL'en, 
nnd  wan  always  regular,  wIlhuuL  piiiu,  uuLiI  lier  marniige. 
Shu  had  always  enjoyed  good  lieuUh,  never  having  liad  a 
day's  illne.<>»  until  tho  present.  fi3iu  was  married  eight 
tnoutiis  ago,  autl  believed  herself  to  he  eight  mouths  preg- 
nnnt.  During  tlio  last  mouth  she  had  freqncntly  com- 
plained of  fftintnesa  towards  evening,  feeUag  as  if  miablo 
to  do  her  work,  but  Lad  never  octuolly  fainted,  or  loft 
any  of  her  work  tindoDO.  Excepting  for  tbiS]  she  was 
(|uite  well  milit  May  10th.  On  that  morning  bor  husband 
aaid  she  complained  uf  a  feeling  of  great  weight  aud  pnin 
Duder  botK  breast^  extending  to  Iho  lower  abdomen.  TLia 
lasted  all  day,  and  she  had  no  appetite.  Bet^ond  tbig  she 
Laxl  uu  cotupluint.  Iu  the  early  part  of  the  uigbt  of  May 
19/20  she  slopt  fairly  well.  Before  daylight  sho  began 
to  suffer  from  nauscii.  She  vomited  sereral  times  during 
the  morning,  aad  thruughout  (ho  day  at  intervals  of  from 
one  to  two  hours  ;  the  vomited  matter  waH  yellow  and  of  a 
so-called  "  bilious  "  nature.  In  the  afternoon  of  May  SOth 
she  begun  to  complnin  of  frontiil  headache,  and  theso  sym- 
ptoms continned  till  the  cvonjiig.  At  7  p.m.,  while  in 
bedf  she  ooaiplaiuod  of  fcoling  giddy,  as  if  the  room  vera 
going  round,  aud  theu  xhu  bad  a  6c,  epileptiCurm  in  the 

VOL.   zxxii.  4 


50 


FUEKPEIUL    KCLAUPStA. 


characters  described,  wliich  was  followed  by  a  aliort  poriod 
of  stupor.  After  tliiti  abt  recovered  couticiuusneas  only 
£or  a  mmute  or  two,  and  then  had  a  second  fit,  which  was 
followed  by  more  prolonged  stupor.  An  hour  after  she 
had  a  third  fit.  Then  alio  waa  conscions  for  two  or  three 
hours,  bat  before  midnight  she  had  a  fourth  lit.  After 
midnight  fits  recurred  with  iucreasiog  frequency.  From 
1  a.m.  to  2  p.m.  on  the  2Ist  she  ha.d  fourteen  fits.  In  tho 
intervals  she  never  properly  recovered  conscionsness,  and 
sho  frequently  vomited.  She  sometimes  passed  water 
during  tho  fits.  About  2.30  p.m.  patient  was  broujjht  to 
the  hospital  and  admitted. 

At  3.20  p.io.  the  following  note  was  made  by  Dr. 
Herman : — Patient  is  reported  to  have  had  a  fit  at  2.30 
p.m.,  was  admitted  at  2.40  p.m.  No  fit  since.  Patiout 
is  rcBtless.  Has  not  spoken  since  admission.  Popils  act 
to  light,  ConjuiictiTic  sensitive,  although  Mousitivoness 
soema  diminished.  Features  swollen,  ©cehymosoB  round 
eyes,  black  omsts  about  lips ;  hands  very  livid.  No  cedema 
anywhere.  Uterua  reaches  nearly  half^vay  between  nrabi- 
lious  and  enuifonn  cartilage  j  no  npprpcinble  dilatation  of 
cervix.  Cartliac  duluess  extends  to  a  iingov's  bruadth 
outside  nipple  line.  No  murmur  at  apex.  Much  rattling 
from  mucus  in  air-piissages. 

3.50  p,iii.  patient  had  a  fit,  followed  by  coraa,  with  ster- 
toroQs  breathing.  The  stertur  lasted  about  ten  miuutes. 
After  this  tho  patient  lay  for  the  most  part  asleep,  iutorvEilii 
of  restlessness  occasionally  intervening.  At  9.35  p.m.  sho 
was  given  a  draught  containing  Chloml  Uyd,  gr.  xxr,  and 
Pot.  Bromid.  3SB.  After  midnight  sho  WflB  able  to  take 
milk. 

May  22nd. — 7.30  Ei.in.  sho  had  a  fit  like  the  former 
ones,  epileptiform.  After  this  she  remained  without  any 
sign  of  consciousness  till  2.30  p.m.  Then  she  spoho  to 
the  nurse,  and  after  this  remained  conscious  till  10.10 
p.m.,  when  she  had  another  fit,  followed  by  a  short  period 
of  stupor. 


4 


b2 


HriBPIftAL   tX-I^HI-BlA. 


TIiu&u  wvrv  left  aided,  sud  wore  not  followed  by  sncli  deep 
comti  as  was  present-  iifter  tbo  earlier  fits.  Ab  9.20  a.m. 
the  patient  begnn  to  trcmbluall  ovor,  but  f&id  she  did  not 
feel  cold.  At  9.50  tlie  trembliug  ceased.  The  tempe- 
rature at  9.-15  was  100";  at  10.45,  lOl-e*.  It  tlion  fell, 
reaching  normal  by  4.-1'),  At  11. ^S  a.m.  patient  coui- 
plaiacd  of  pain  in  the  lower  abdomi^u,  luii)  siiid  she  fell 
Eometliiiig  coming  away  from  her.  Thts  nurse  toukod,  and 
found  tliat  tho  child  had  been  expelled  into  the  bed,  Tho 
foetus  was  uiacarated,  and  apparently  about  seven  month-n' 
development.  The  resident  accoucheur  was  then  cnlled, 
aud  expressed  the  placenta  with  some  difficully  nbont  half 
Bu  hour  after  the  birth  uf  thecliilil.  There  was  but  little 
LieiQoiThage.  Half  a  grain  of  crgotiu  was  injected  8ab- 
cutanoously  after  tho  delivery  of  tho  placenta.  At  2.50 
p.m.  piitiont  began  to  x'oniit,  and  this  coutiiiued  inces- 
Hantiy  UU  8.15.  The  vomited  matter  wna  yellow,  acid, 
bilious-loolcing.  Bliu  uuniplaiued  oecasinnally  of  pnin  in 
the  head  and  abdomen.  The  nursH  also  reported  that 
she  "  talked  strangely  ;"  fancied  that  she  could  see  people 
and  things. 

24th, — Patient  slept  Fairly  well  during'  the  early  part 
of  last  uight,  except  that  she  was  a  little  restless  at 
times.  She  wok»at  8.15  a.m.,  and  soon  after  waking- com- 
plained of  headache.  During  the  day  she  was  rcsllcfw, 
and  vomited  once  er  twice.  She  took  nourialnncnt  fairly 
well.  About  6.30  p.m.  she  suddenly  became  TioloDt, 
clntohing  at  the  nnrsOj  and  s-aying  she  was  being  poiBoned, 
killed,  &c.      She  was  given  Morphia  gr.   \,  and  Atropiu 

25th.^Aftor  tlio  administration  of  the  morphia  and 
utropin  the  patient  slept  till  -1  u.uu,  being  wakened  about 
every  two  hours  for  the  administration  of  brandy  and 
milk.  About  4-  a.m.  kKo  became  rather  excited  and 
talked  at  random,  but  showed  uo  violence.  Then  she 
slept  and  perspired  very  profuaely.  About  5.30  a.m.  she 
was  wakened,  and  spoke  quietly  and  rationally,  complain- 
ing ot   giddiness.      U)  a.m.    pntiout    ^turted    up  in    bodj 


poicRrBnAr,  bclaupsia. 


68 


snying  tliero  was  n  mouse  running  ov«r  it ;  asked  for  her 
clothea,  and  talked  contiiiimlly  abuut  mice,  saving  th&y 
wore  rnnning  about  tlio  room.  At  II  a.m.  a  duse  of 
atropJD,  -^i  was  g-ivco  ;  but  as  this  failod  to  cjuiet  her,  at 
11.20  a.m.  Morpbia  gr.  ^  was  g'iveii.  At  11.50  a.m.  the 
patjont  went  to  s\cop,  and  slept,  excepting  when  roused 
for  Food  oi*  modiciiio,  till  4  p.ui. 

26lh. — During   this   day   slio    was   cjnietor,  sleeping  a  ' 
gixjd  deal,  and  sensible  when  awake.      She  vomited  four 
or  fiTO  times,  but  took  a  fair  ammmt  of  noiirishiuent. 

27th. — Patient  .slept  last  night  ii-oiti  0.30  p.m.  to  6  a.m. 
Talked  a  good  deal  in  her  sleep.  No  inoi-c  vomiting. 
In  qaieter  and  rational. 

iSth. — Patient  had  a  good  night,  only  waking  to  take 
food.  Is  this  morning  quiet  and  sensible,  atid  answera 
questions  rAtionaliy. 

SIst. —  Pationt  sloops  and  takes  food  well.  Locbial  dis- 
eharge  nalural. 

June  7th. — DUoharged, 

Temperatitrp. — The  l-omperHtnre  was  taken  every  hour 
until  twenty-four  honrs  after  the  last  fit.  Then  it  ivaa 
tiiken  every  foiir  hours  for  a,  week.  From  that  liniL'  till 
patient's  discharge  it  was  taken  night  and  uiorniug.  Oa 
admission  (pationt  liavin>j;  had  eighteen  Hts  during  tho 
I  previous  nineteen  boiii-s)  the  temperature  was  lOif.  It 
iraa  ^O'S"  an  hoar  afterwards,  when  tho  patient  had  tha 
first  6t  after  admisBiou.  During  the  next  fourteen  hours — 
tlint  is,  up  to  the  time  of  tlio  next  fit — it  varied  between 
PO'g"  and  ]00'6°,  huTing  fallen  from  the  latter  point  to 
100  2°  at  the  time  of  the  fit.  Then  it  gradually  fell,  and 
at  the  liaio  oF  the  next  fit  (viz.  10.10  ou  the  oveiiiug  itf 
the  day  Fullowiug  admiiutioD)  was  07*8°  During  the  noxb 
nine  buurH  it  remained  Hubnorraal,  and  during  this  itme 
the  patient  hatl  twn  moro  fits.  Then  came  the  attack  of 
trembling  already  mentioned  ia  the  notes,  in  the  two 
huurt  foilowing  which  tho  temperature  roae  to  lOPO". 
In  tUo  next  two  hours  it  fell  lo  101^  and  three  hours  after 
that  hud  become  normal.     I  cunuot  offer  any  osplunation 


KCLAXPSU. 

of  this  brief  ris©  of  teraperatnre,  auless  the  naental  per- 
turbation caused  by  the  onset  of  labour  pains  bo  accepted 
ail  sufficient.  After  the  tenipcrafciiro  liad  subsided  vomit- 
ing began.  During  tlie  next  day  the  tcmpepatnrc  was 
nonuttl  until  8  in  the  cveaiug,  when  it  rose,  reaching- 
101*4*  at  midnight,  nnd  102'4°  nt  4  a.m.  Then  it  again 
fell,  being  normnl  at  midda)*-  This  elovfition  of  tempera- 
ture wfts  Accompanied  hy  montnl  excitement,  and  as  the 
teraperntm'G  coutiiiued  to  riso  during  sleep  produced  by 
morphia  and  atropin,  I  am  luclined  to  think  the  mental 
excitement  depended  on  the  febrile  state,  ratlier  thai)  that 
the  temperature  depended  on  the  mcui&l  exoilemcnt.* 
After  this  no  noteworthj'  clcration  at  temperature  oc- 
curred. 

Urine. — Instructions  were  given  that  the  urine  should 
be  drawn  off  hourly.  Notwithstanding  that  thi»  nus  done, 
the  imtic  was  so  frcquentiy  passed  inbod  thnt  it  was  inipos- 
siblo  to  collect  «U  or  nearly  nil  that  wn«  passed,  I  think 
that  the  hourly  uae  of  the  catheter  waa  too  frequent,  and 
I  am  inclined  to  attribute  to  it  the  irritability  of  bloddei* 
which  defeated  the  object  of  the  catheterisation.  I  give 
the  results  obtained,  imperfect  as  they  are.  AUhuugh 
they  do  not  give,  as  it  were,  a  complete  picture,  yet  they 
Furnish  glimpses  which  are  accurate  us  far  ua  they  go. 

Qaantittj, — The  chart  shows  the  amounts  of  urine 
drawn  oS  when  the  cutheter  was  not  nnticipiited  by  in- 
fluences causing  the  bladder  to  empty  itself.  The  cutheler 
was  not  passed  till  an  hour  had  elapsed  from  the  last 
emptying  of  the  bladder,  so  that  each  amonnt  withdrawn 
shows  the  hourly  excretion  of  urine  at  thnt  time. 

Tho  dots  on  the  chart  show  the  amouuta  actually 
drawn  off.  The  crosses  indicate  that  the  nrine  was 
passed  in  bed,  or  with  tho  stoola,  or  in  a  fit. 

During  the  first  seven  hours  the  attempt  at  collecting' 
all  tho  urine  was  ttucce<ssful.     The  chart  shows  a  rate  of 

•  IIoiuiu  {'ZeiUcli,  £ur  Oub.  iind  Ojn..*  Band  xv)  Iim  brouBlit  forward 
cvidorii-'u  a*  to  tLie  coniicvlioji  bolwi-uu  pyrciJii  iu  tlic  ptierpuml  state  and 
iiH-utal  djatiirbitiice. 


TTIERFFUAt.   KCUUPSrjL. 


5£ 


Qrino  oxcrction  vnrvinff  from  zero  to  li  oz.  per  liour,  an 
average  of  about  3:Ifi  minims  per  hour,  about  ono  third 
tho  nvepflge  of  Iienllb.  We  omy  safely  conclude  that  in 
this  case,  at  tlie  Leigbt  of  tho  diaeast',  the  quantity  of  urine 
excreteil  was  much  diminisTicil.  Then,  unfortunately, 
cotnes  a  long  period  in  which  most  of  the  iirinp  was  lost ; 
but  the  resnits  of  occa&ioual  ciithctevism  .show  that  the 
amount  of  uriiie  was  still  scanty,  ^  oz.,  2  dr.,  and  on  two 
occasions  none  at  all,  heiug  the  (]iiai]tities  of  urine  Found 
in  tho  blikddcr  au  hour  after  urine  had  been  passtid.  Ahont 
twenty-four  hours  after  deHfery  the  chart  shows  increas- 
ing amounts  of  urine  to  have  been  ponrcd  iuto  tho  bladder, 
i^  OE.,  2  oj!.,  3  oz.,  4  07..,  and  4^  oz.  being  withdrawn  by 
tho  catheter.  This  inoi'c  abundant  excretiun  of  urine  took 
pinco  about  the  kbiuu  time  as  the  later  fits,  which  were 
followed  by  briefer  coma  than  the  earlier  ones.  Tho 
largest  quantity  of  urine  found  to  have  been  excreted  in 
an  hour,  vix.  4i  oz.,  immediately  preceded  the  last  fit. 
After  this  the  returna  are  too  incomplete  to  be  worth 
record.  But  the  fragmentary  observatiouB  which  I  have 
recorded  show  that  during  the  stress  of  the  disease  the 
qaantity  of  urine  was  much  diminished,  niid  re-establish- 
meat,  and  it  eeoms  iudood  incroaae,  in  the  amount  of  nrino 
excreted,  preoeded  the  cesHatiou  of  tht  fits. 

Specific  griimtfj. — The  quantities  of  urine  withdrawn  at 
each  ealheterisation  were  too  Rraall  for  the  specific  gravity 
to  be  easily  ascertained.  I  therefore  have  only  records 
of  the  specific  gravity  of  different  specimens  of  each  day 
mixed  together.  On  tlie  day  of  adriilssiou  the  spE>ciHc 
gravity  wais  1Q-I4.  I  havu  unfortunuteEy  no  record  of  the 
specific  gravity  of  the  next  day  ;  hut  on  the  third  day 
(the  lust  St  having  boon  at  7  a.m.  on  that  day)  the  specific 
gravity  had  sunk  to  10:20.  No  important  variation  ia  ob- 
serrablo  after.  The  speciSc  gravities  were  as  follows  T 
Hay  24th  (fourth  day),  1020;  May  2.ith,  1024;  May 
2Gtb,  1025;  May  27th,  1025  ;   May  30th,  1024. 

Albumen. — On  admission   the  urine  was    nearly    golid 
when  the  alburaen  was  precipitated,  &nd  each  specimen 


64 


POKHPRBAL   KCUHPSU. 


withdrawn  contained  a  little  blood.  On  the  following  day 
the  amoaut  of  albumen  hnd  sunk  to  about  hiilf ;  a  little 
blood  was  still  pres&ut.  On  the  tliird  day  {day  of  cet«nlion 
of  fits  and  delivery)  the  qnantity  ui  albumen  was  about 
the  BADie,  hut  there  was  no  longer  hlood  in  the  nriiie, 
which  from  this  time  oiiwai-ds  gave  a  deposit  of  urates. 
On  the  Eoarthday  theqaaatityof  albumctthadsunk  to  about 
one  fourth  or  one  Bfth  ;  ondu  similar  uniDuut  was  pi-est-nt 
during  the  next  two  days.  Ou  May  27th  the  ulbuniiuuria 
had  stiuk  to  oue  teuth.  At  the  time  of  discLarge  there 
was  a  scarcely  perceptible  trace. 

Urea. — The  percentagu  of  urea  was  ascertained  by  the 
Eussell-West  hypobrouiate  process.  I  am  indebted  to 
Mr.  Duigan  for  his  trouble  in  doing  this.  The  collectlnn 
of  the  urine  being  so  imperfect,  I  refrain  from  attempting 
any  estimate  of  the  total  rjuantity  of  urea  eliminatod. 
The  percentages  of  the  different  specimens  are  shown 
on  the  chart.  It  will  be  seen  that  the  percentage  of 
urea  was  not  at  &U  Jiminisbed.  Ou  the  day  of  admicsion 
it  corresponded  to  what  would  have  been  expected  from  the 
specific  gra\'ity  of  the  urine.  On  the  two  following  days 
it  was  alightly  increaKed,  and  was  in  escesHof  what  would 
have  been  inferred  from  the  specific  gravity.  Then  it 
sank,  and  later  on,  when  the  albumen  had  diminii^hod  lo 
a  trace,  tho  percentage  of  urea  again  correBpouded  to  the 
specific  gravity  of  the  urlue. 

Depofrit. — On  May  30th  gome  granular  casts  were  de- 
posited. At  no  other  time  wore  casts  found  in  the  urine  ; 
but  as  the  quantities  examiued  were  very  small,  I  do  not 
from  this  infer  that  casts  were  not  present. 

October  2l8t,  1889. — Patient  has  not  menstruated  since 
the  middle  of  July.  Thinks  herself  pregnnni.  Uterus 
presents  all  the  Higus  of  pregnancy  at  the  period  stated 
by  patient.  Patient  complains  of  headaclie,  coming  on 
BTerj'  other  day,  and  lasting  all  day,  but  thinks  herself 
otherwise  well.      Is  not  antemic.     No  cudenia. 

Urino  1010,  acid,  clear,  do  albumen. 

In  this  caao  the  njcurronce  of  fits  was  protracted  over 


POBRrBKAL  RCLAMrSU.  bi 

a  longor  period  tliau  usual.  Tlie  case  also  kIiows  iTmt 
ri«o  of  temperature  is  at  least  aoi  an  iuvariablo  ecquol  oE 
the  fits.  It  aUo  snggcats  tlwit  tho  coma  following  the  fit 
is  not  im  effect  of  the  convcilsiou,  but  that  cooviilaion  and 
coma  are  alike  eiloctg  of  the  moi-biil  condition  (-auBitigtlii- 
fopoier :  for  iu  this  case  fits  coutinued  to  rocur,  ulfhuu^'li 
the  tentperatnre  vva.s  falling  and  the  aiiiount  nf  iirine  in- 
creasing ;  biit  tha  later  (its  differed  from  the  earlier  otips 
in  not  beings  follonrod  by  [irolungcd  comu. 

GRNBRAr,  Hkharks. 


These  live  cases  appear  to  me  ta  exhibit  facta  bonring 
opon  tnnjiy  poitita  of  interest  in  the  clinical  history  of 
oclautpsin.  But  T  shall  only  dwell  iipen  one  point,  wlbich 
appeorg  to  me  to  be  the  main  odo  which  tliey  demonstrate. 
They  go  to  show  that  puerperal  eclampsia  is  not  a  disease 
Imving  H  unifurm  tyjiical  clinical  history,  any  more  than 
it  haa  a  anifonii  morbid  anatomy.  Kchanta,*  who  I1118 
givcu  tlio  fulleftt  accoiint3  of  the  morbid  unulomy  that  I 
am  ncquainted  with,  found  the  fotlowiujf  different  renal 
changes  pru&cut: — ttcuteticphritts,  chronic  Ilright's  disease, 
acute  nephritis  upon  chrouio  lardaceous  disease,  hydro- 
nepbrosis,  ditutatiou  of  ureters  and  renal  calices,  and  in 
otber  csHes  no  renal  change  appreciable  by  tbo  unnidod 
BODseit.  Now,  wben  the  post-morlem  chaiigfesaro  so  various 
one  would  espect  differences  in  the  clinical  history  iilsn. 

Tiio  resoarclies  of  Boiirneville,  Galabin,  Quincke,  iiiid 
otheni,  show  that  many  cases  uf  eclampsia  avi^  accompnnied 
by  ulevaiiuR  of  Icmporature,  which  in  fntal  ciiscs  siuadily 
rises  until  death.  Clalabint  expresses  the  opinion,  winch 
I  think  has  much  in  its  faTour,  that  the  c-tcFntion  o£ 
temperature  is  duo  to  the  fits.  H  Ihin  be  correct,  the 
elovatioD  of  temperature  eliould  bo  somewhat  iu  prupor- 

•  ■  Arcli.  fur  Ojn.,'  BntiJ  iTiii,  S.  »77. 
t  •  Mufiual  of  UiJwir^ry,'  p.  299. 

{  ■  fituitr*  cliniiiuei  vt  tlitnuan'.ftlrii^tiea  tar  Im  maladiM  du  Ajttcai«  net- 
i,*S*fiw.,  F«ri».lt»7S. 


PriRPEBAL    ECLAMPSIA. 


tion  to  the  omnljer  of  tlie  fits,  anfl  tlie  fits  ahoiilcl  be  fol- 
lowed by  rise  of  teiuperuttii-e.  Boiirnevillet  has  drawn 
a  diatiaution  betweeu  puerperal  eclampsia  aud  ordinary 
urfBnii»,  by  contratiiing' the  rising  temperature  of  eclampsia 
with  the  falling  one  of  iirfemia.  Hippolyte,*  regarding 
pyrexia  as  an  essential  feature  of  the  disecise,  quoto»^  cases 
in  which  treatment  by  bEeeding,  clilorofonn,  and  chloral 
was  followed  by  lowering  of  temperature,  the  trt-atment 
niid  the  falHtig  teQipenituro  being  by  him  regarded  as 
cause  and  effect,  and  the  latter  therefore  a.  proof  of  the 
efficieuoy  and  value  of  such  treatment. 

From  these  five  ca-ses  I  can  exprcBB  no  opinion  as  to 
whitt  may  be  true  ia  the  majority  ;  but  these  show  that 
tin-  general i?;fltions  cjuoted  do  not  hold  good  of  all  cases. 
In  the  only  one  of  these  cases  that  was  fatal  the  tempera- 
ture was  never  above  normal,  and  fell  to  subnormal  before 
the  termination.  In  Case  5  the  fits  were  not  followed  by 
a  rise  in  temperature,  but  by  abatement  of  pyrexia,  the 
body  teat  sinking  to  normal  although  fits  oontinned,  I 
may  also  point  out  that  in  Cases  1  and  !)  tlii?  teniporature 
rose  slightly  after  ehloml  and  chloroform  had  been  used. 
But  without  a  more  exact  knowledge  than  we  at  present 
have  of  the  conditions  upou  which  the  temperature  inthiit 
disease  depends,  we  cannot  safely  conclude  that  alterations 
in  the  temperature  are  the  effect  of  treatment. 

It  is  stated  iu  most  text-books  that  in  this  diseaae  there 
14  a  great  diiuinutlon  in  the  quantity  of  urine.  I  do  not 
doubt  that  this  slateDieut  ia  true  of  most  cases.  But  in 
Case  3  of  thi^  eerie.s  there  was  copious  diure&is  during  the 
6ta,  still  further  inereased  after  delivery;  and  in  Case  4, 
the  (atal  one,  an  increase  in  the  quantity  of  urine  passed 
preeedeil  the  fits  and  nccomptmieil  them. 

It  is  well  known  that  ntbumiuuria  rapidly  diminishes 
in  these  cases  after  delivery.  In  Caries  2  anil  5  the  albu- 
minuria began  to  diminish  after  iha  ceBsatiou  of  the  fits, 
and  before  delivery.  It  has  been  maintained  that  the  albu- 
minuria is  due  to  the  fits  ;  and  in  its  bearing  on  this  theory 
*  *!>«  r&lnuipiio  iiu<!i'|i^nilt(,'  Purie,  1S7K  p.  329. 


PUEKPERAI.   ECrAMPfll*.  69 

Chaa  2  is  interesting,  id  wbicli  the  fits  were  follonred  hj 
an  increase  in  the  ainoant  of  albumen  iu  tite  urine. 

In  all  the  cases  t!io  excretion  of  urea  was  diinin- 
islied  during:  tlio  Sts.  Tliere  was  in  mot-t  &  diminution 
both  in  tho  percentngo  of  uroa  and  in  the  quantity  of 
urine.  In  Case  2,  in  which  tho  qnantity  of  urine  was 
above  tho  average,  the  perceutag-e  of  nrea  was  mnoh 
diminished,  so  thnl  the  riite  of  urea-elimination  wasscaTOPly 
half  that  of  health.  In  the  case  admitted  for  Bright's 
disease,  in  which  convulsions  supervened,  and  dealh  fol- 
lowed, the  excretion  of  urea  wa.s  throughout  bt-low  that 
of  health.  In  all  the  patients  who  recovered,  increase  ia  tho 
elimination  of  urea  followed  cessation  of  the  fitsaud  delivery. 

I  put  aside  controversy  as  to  the  part  which  urea  in 
tho  blood  or  tissues  plays  in  exciting  convulsioun.  It  is 
sufficient  jnBtificntion  for  troubling  the  Society  with  the 
details  o£  those  cases,  that  it  is  generally  admitted  that 
the  amount  of  urea  eliminated  is  the  best  guide  we  have 
to  tho  functional  activity  of  the  kidney  ;  and  if  this  be  so, 
the  value  of  these  records  is  the  game,  whether  the  fits  bo 
due  lo  urea,  or  to  products  resutlicig  from  the  decomposi- 
tion of  urea,  or  to  waste  products  which  ought  to  bave  been 
courertcd  into  uron. 


Dr.  Pbikstlet  said  tbut  the  HiDcere  tlitinlig  of  the  Society 
wen>  due  to  Dr.  Honiiau  Tor  tbe  gM>;iit  euru  mid  zeitl  with  which 
hia  obserrations  on  ttio  varying  conditioiit)  iu  ci-lauipuiu  liaJ  been 
conducted.  It  was  oidy  by  such  carprully  recorded  facts  ifiiit  the 
true  patholog}'  of  tlie  obai^iiNt  dineaKC  wa«  liltply  to  be  i-lucidaled, 
and  it  uM  obvious  tliat  luuch  jrct  romoiued  tu  l>o  le&raed  about 
it.  It  was  ililHcidt  to  discUAB  the  jiapi-'r  in  all  it»  beariiign,  but 
one  fact  struck  him  particularly,  va.  the  abiienee  of  thnt  high 
tomperaton*,  ta  indicated  by  the  tiiermo meter,  which  had  been 
pointed  out  by  writom  on  the  Contincat  m  uaunlly  present 
during  the  progress  of  puerperal  comuisions.  It  was  bt^ld 
almost  ft«  an  article  of  failh  in  France  and  Germany  that  higti 
pyrexia  (specially  pertained  to  attacks  irf  eclampsia,  the  tL-i[ipLTa> 
turu  rising  su  hi^^h  in  suint;  CAse»  a.*  43"  C,  ur  about  lOd''  F.,  and 
inorvasiiig  from  the  beginning  ofa  fatiil  attack  to  tbc  end  -,  while 
with  conviilsioua,  tliu  result  o(  gonoral  urienua,  the  temperature 
fell  progri-tiiively  uutil  death.      Wiuckel  claimed  Rrat  to  have 


TirEBPCaAL  SCLUMPRIA. 


I 


pfliiitci]  nut  tlie  remnrkable  rise  ia  tempernfiire  during  tite 
paroij-sms  of  eclampaia  :  and  Charpentier,  in  controverting  liia 
claim,  maltea  a  severe  attack  upon  him  for  advancing  it.  The 
Inat-amnecl  author  Bka.U;a  iliat  Kien  toarle  t!ie  lirst  eenoun 
rcBearcIiOH  witli  the  tliermoinetor  in  eclaiupBia,  anil  after  liim 
]luurDi.-vili«  und  Butlin.  Dr.  IIvrtiian'H  paper  vaa-  il  suffiei^iit 
]>ri)i>l"t'iiat  wo  were  nut  yet  inpoaHCHBioDof  all  the  patbologicuL  facta 
relating  to  the  various  forma  of  puerperal  eclampsia,  and  lie  had 
cortaiiily  proved  that  the  iliaeaae  had  not  a  uDitbrm  clinical 
history. 

Dr.  ilooBOCsa  quite  agreed  that  there  was  a  raried  cliuical 
Ihistory,  OB  weiL  as  a  varied  morbid  anatomy,  in  csbbb  of  puerpenit 
eclampsia,  i'riamrily  they  were  divided  into  two  groufe  as 
eneentiftlty  distiuat  as  npili-pB)-  mid  uricmic  convuIeioaB,  nnuiely, 
i\wsu  in  whivh  tlifrc*  was  uo  albumen  in  the  uriiie/and  those  in 
M'hiL-li  there  was  albumen,  often  in  large  qu&iitititiH.  He  believed 
that  the  ialti;r  group  at  Icatit,  and  pcThapa  the  former,  might  be 
Ktill  further  subdivided,  aeeording  to  differences  in  pathology. 
But  not  kuowiiigvBt  how  to  dittiiiiguiMh  tliuse  diHV'rencect,  he  lind 
hitherto  treiited  too  uou-albuminuriu  casea  na  cases  of  epilepoy 
complicating  pregnancy.  In  nil  theiie  he  bad  Bduiinistered  largo 
doaes  i)f  broniidu  of  potasBinni  per  rectum  ;  la  one  ckbg  as  much 
a»  iiiucty  grains  werti  giion  ibis  wity  in  viie  dose,  and  Ihe  patient 
recoKrcd.  Ue  had  luid  anutiier  caae  with  Dr.  Marsball,  of  Ber- 
mondsey,  but  the  patient  died.  Kegarding  the  other  cases  ia 
wliicb  aibuineu  naa  found,  t!ie  aduiiiii^tration  of  morphia  ^aa 
pL'i'liaps  dangerous,  cspfcially  wlierc  tlie  uriemic  element  pre- 
VilIled^  Tlio  reeenrt'h'es  rt-gardiiig  the  tempL-rature  aud  ihoqiiau- 
tity  of  u.rcii  ^xeroted  vicre  very  valuabif-,  and  his  own  experience 
was  that  t1io  temperature  was  raided  an  a  rule,  and  in  eoine  cases 
he  bad  found  that  it  continued  to  rise  for  a  few  hours  after 
doath. 

Dr.  W.  8.  A,  GairrrTiI  remarked  that  there  were  tivopointa  in 
the  elinicsl  history  of  thenephritiB  of  pregnancy  (with  or  without 
puerperal  t'clampsia)  about  which  informalion  »"ii.«  much  ueeded. 
The  Qrift  bad  to  do  with  thi;  origin  ul'  the  diaear-e.  In  what: 
proportion  of  cusfa  had  there  been  any  evidence  of  prc-eiiating 
iicphritiH,  cutiipliealiug  Evarlutiun  or  diphtheria,  for  instance  i* 
The  other  was  the  termination  of  the  liiaeaee.  Ifow  many  casca 
died  eveiilually  from  or  with  kiiliiey  diacapc?  It  was  geueralLy 
hdil,  ho  tbou>^)u,  that  the  di»ea»o  una  teiaporary,  and  that  ia 
favourable  casi-s  recovery  aooQ  took  place.  In  discwsg-ing  the 
qucation  Dp.  &ee  bad  stated  to  him  that  in  bis  experience  very 
itinny  of  tlieno  cjisfs  in  later  life  developed  eymptonia  of  chronic 
kidooy  diicoso.  Dr.  Uritllth  would  be  glad  if  l>r.  Herman  could 
give  him  any  information  on  these  points. 

The  PaemuiiX'r  said  that  he  thought  that  the  theory  pro* 
jtonnded  by  BounieTille  that  eclamptic  atlacbs  raised  the  tem- 


rUKlU'BKAL   ICLAMfSU. 


•  )l 


pemturc,  wliilo  uncmiA  lowered  it.  applied  not  niily  to  B^|i8rAle 
cases,  but  to  the  dilTerent  elementR  in  the  e&mtt  cute.  If,  there- 
fore, the  urttmic  conditiooti,  tte  evidvaced  l>y  iJimLDi«bcd  KcreUoa 
of  urea,  preponderated  in  proporlion  to  the  frequency  of  tlie  con- 
vuliionn,  it  might  be  expccti^il  that  the  Blcvntiuu  uf  tL'm|)t>riiturQ 
would  be  int«rfcrcd  witii.  He  asked  Dp.  Herman  if  tliia  pHu- 
ciple  would  explain  any  of  the  annmnliea  obnerved  in  his  casOT. 
Agun,  in  bis  fxperleitpe,  it  was  elilefly  in  uiitrentcd  crhus  thnt 
veiy  murked  elevation  of  temperature  occurred,  nnd  chlitrofopra 
or  Ueudiog  vapvciully  coutitcructcd  it.  In  oue  auu,  utitruated 
until  tbe  (latletit  was  nionbuDd,  he  had  found  the  temperature  as 
hiph  M  llOf. 

Dc.  Ukuuax,  ill  reply,  »ai>[  that  nltliuugh  lie  had  quutcd 
Itounievillc'n  paper,  he  had  not  iuLi-nded  l>y  iloius  bo  lo  imply 
any  oitiriion  ue  to  the  quosticm  of  priority  b«tw(]^oii  him  and  Prof. 
AVinvkel,  He  agreed  with  Dr.  Uorrocke  that  cases  of  eclampsia 
without  albuminuria  were  very  different  fniin  casea  with  nlou- 
minuris,  aud  lie  would  add  that  catcii  in  whieh  tliere  wan  a  mcrt! 
trace  of  albumen  were  luile  difl'crcnt  from  1ho*e  in  which  tho 
urioc  wa«  eu  loaded  with  albuiut;u  as  to  become  uearly  solid  on 
boiling,  MS  in  thu  caseM  now  related.  The  oni?  fraturv  which  all 
thcHG  cftiKia  had  io  common  was  a  diminution  in  the  excreliun  of 
urea  dtirinj;  tbo  time  in  which  the  Cilti  weiv.  ai'currnj;^.  Thcue 
caaca,  bo  far  aa  they  went,  did  not  mipiiod  iIil'  view  tiiivt  thu 
cIuvatiuQ  of  torn peral ui-o  was  in  pniportioii  to  the  numhur  uf  the 
filfl,  for  Caac  5,  in  which  the  fits  were  uoat;  uuucruue,  hnd  uut 
tho  highest  temperature. 


ANNUAL  MEETING. 

Febhdaky  5th,  1890. 

AiruD  L,  Gajabin,  M.D.^  Frcsidemt,  in  the  Chair. 

Preeent — 41  Fellows  and  1  Visitor. 

The  President  declared  tlie  ballot  opcu  for  on o  1) our,  iiud 
appointed  Dr.  Clapbam  niid  Dr.  Diikiu  as  scrutineers. 

Cbicliester  (J.  May,  M.A.,  M.B. Cantab. ;  Charles  Heury 
James,  L.K.C.l'.Lond. ;  and  Tbomaii  Kdward  Pai-60u8, 
M.R.C.S.,  were  admitted  Fellows  of  the  Society. 

Edward  H.  Douty,  M.A.,  M.B.,  B.C.Cantnb.  (Cam- 
bridge)  ;  J.  Arthur  Hclme,  M.D.Ediu,  (ManuhcBter)  ;  and 
'lliomuH  Riubmund,  L.R.C.P.Edin.  (Qlusgow),  were  declared 
admitted. 

ITie  following  gentlemen  were  elu'ctcd  Fellows  of  tlie 
Society: — Christopher  Martin,  M.B.,  C.M.Ediii.  (Mid- 
dlosbrougb]  ;  Benjamin  Wilfred  Tlionias,  L.B.O.P.Lond. 
(Welwyo) ;  aud  George  Porter  Worauiu,  M.R.C.8. 

The  following  geutlomeu  were  proposed  For  election  : — 
William  John  Gow,  M.D.Lond.  ;  and  Aylmer  Orr,  M.A., 
U.B.Oxon. 


64 


DOUBLE    PYOSALPINX. 
Bj'  CitaitLBS  H.  CArrEB,  M.D. 

The  Epeciiuen  was  removed  by  alidomiiial  section  from 
B  putieut  aged  24,  married  two  niidalalf  years,  but  ucvcr 
prcguaut.  She  hnd  suffered  from  dyspareimia  and  pain 
for  tho  lust  twelve  months,  and  these  symptoms  had  in- 
t-rea)ied  during  tlie  last  six  months,  so  tba.t  she  was  uuablc 
to  wiUk  any  distanco,  or  quickly.  SIib  hud  nevt-r  had 
any  vaginal  discharge,  or  pain  or  trouble  on  micturition. 
The  catami-nia  began  at  fourteen  ;  pre-menstrual  pain 
uaiially  lasted  three  to  four  ilriys  ;  worse  since  marriage. 
Period  used  to  last  three  to  four  days,  during  the  last  two 
years  it  lasted  five  to  six,  and  the  loss  was  greater. 

Till!  husband  says  lie  had  gleet  sevea  yenrs  beforo  ho 
was  nian'icd,  bnt  was  well  at  the  time  of  naarriago. 

On  vaginal  examination  the  uterus  was  found  to  bo 
pnslicd  downwards  and  forwards,  and  tbe  two  tumoura 
were  felt  one  on  each  side  behind  the  uterus,  and  move* 
able  to  Kouio  extent.  At  the  operation  both  were  adherent 
tij  the  peWic  floor,  and  were  shelled  out  with  difficulty. 
To  the  left  tumour  there  was  a  wide  omental  attachment. 
The  right  tube  was  five  iuclies  long,  the  ovary  closely 
attached  tu  it,  and  on  cutting  into  it  about  2  ok.  of  healthy 
pus  escaped,  The  left  tube  was  about  four  inches  long, 
and  eai:b  was  about  two  inches  in  circa  inference.  Tiie 
putiuut  tuado  an  uainteriuptod  recovery. 


CYSTIC  DISEASE  OF  THE  CHORION. 

By  A.  K.  Auai  Lawuenck,  M.D. 

Dk,  Ai;K'r  Laweexcb    exhibited    a  specimen    of    eystic 
disease  of  the  chorion.     The  patient  was  only  two  uuuths 


CrSTIC    DISSA^SK   nr   THS   CBOBION. 


65 


prcg^iant,  yet  her  uterus  was  of  the  wize  asDally  attained 
at  the  eighth  month.  Tlia  enlargement  was  due  to  con- 
ccikled  hnemorrhage  and  the  diseased  chorion.  The  uterus 
was  cleared  out  and  the  patient  did  well. 

Dr.  Anst  Lawrence  l«id  stress  on  two  points  in  the  dia- 
gnosis. Firstlj",  the  enlarged  uterus  is  alwaja  out  of  pro- 
portion to  tlie  date  of  pregnautj  ;  aud  secoudly,  the  form 
of  the  uterine  tumour  is  always  irregular,  not  at  all  like 
a  pregnant  uterus  of  a.  corresponding  sixe.  As  for  trcnt- 
uient,  the  uterus  eboutd  be  cleared  out  as  soon  oa  the 
diseased  condition  is  recognised. 


CYSTrC  DFRKASB  (HYDATIFORM  DEGENERA- 
TION) OF  THE  CHORION. 

By  John  Phillips,  M,D. 

Db.  Jobs  Phillips  oxhiljited  a  portion  of  this  morbid 
product  of  conception.  The  patient  was  aged  42,  and  the 
mother  oE  severol  children.  She  supposed  herst'lf  four 
months  pregnant,  and  was  certain  of  the  occurrence  of 
foDtol  moremeuta.  She  had  been  floodiag  iucessantly  for 
three  wcelis.  Her  condition  when  £rat  seen  was  alarm- 
ing,— oedema  of  the  feet,  legs,  und  bands,  the  pulse  140, 
respirations  42  per  minuto,  and  tho  uaaal  necompanying 
signs  of  prof  uflo  hafmoi-rhago.  The  uterus  extended  about 
two  inches  above  the  umbilicus,  and  no  fa>tal  heart-sounds 
were  audible.  Thc>  os  utori  was  dilated  to  the  size  of  a 
sixpence  only.  Ethpr  was  given,  and  after  preliminary 
dilatation  with  Barnes'  bags  the  whole  mass  was  scraped 
out  of  the  ut-erine  cavity.  Easy  recorery  followed.  No 
albumen  could  bo  detected,  and  the  cederaa  of  tho  legs 
nnd  hands  was  gradually  disappearing.  No  truce  of  a 
fcetns  was  discovered.  The  interest  o£  the  case  lay  ia 
the  qaestioQ  of  the  diagnosis,  which  it  was  almost  impoa- 

voi:»  xxsii.  d 


HJKMORRaAGE    KBOM   THK    OTKBIWI!   WOCOICS   MEMBRAXK. 

siblo  to  miiiko  from  plncpnte  prsevift  until  the  introduction 
of  the  band  into  tlie  atei-UB. 


UTERUS  AND  APPENDAGES  OF  AN  INFANT; 
HAEMORRHAGE  FROM  THE  UTERINE  MUCOUS 
MEMBRANE. 

By  C.  H.  James. 

Me.  C.  H.  Jamis  showed  tlie  uterus  and  appendages 
of  a  ctild  aged  5  daye,  wlio,  ou  the  day  previous  to  death. 
Lad  a  Banguineous  discharge  from  the  vulva.  Tie  child 
wati  weakly  and  prematare  (eight  inouthsjj  and  took 
nourishment  very  badly.  There  was  no  Bwclluig  o[  the 
breasts  and  no  jaundice.  The  la-bonr  had  been  natural 
and  easy.  On  laying  open  the  uterus  »t  the  post-mortGin 
examination,  the  mucous  membrane  of  the  body  was  red, 
swollen,  and  covered  with  bloodj  but  the  cervical  mncoQS, 
memhrane  appeared  healthy.  No  digease  was  detected' 
in  any  organ,  except  the  liver,  which  waa  pale  and 
yellowish  in  the  centre.  A  discharge  of  blood  from 
the  genital  organs  in  new-born  children  has  frequently 
been  noticed,  but  it  is  rare  fo  get  an  opportunity  of 
domonstratiug  its  source  from  the  uterine  mucous  mem* 
brace. 


Dr.  Ccllisowobth  eaid  that  some  yenre  ago  be  took  great 
trouble  to  collect  all  tlie  case^  lie  cuuid  find  recorded  of  Iwmor- 
rliage  from  the  goiLital  orgaiii  of  the  newly-botn  femnle  child. 
He  had  embodied  the  results  in  a  paper  published  in  the 
'Liverpooi  and  Manchester  Medical  aud  Surgical  Reports.' 
This  ciLse,  tbererore,  wtts  of  special  interest  to  him,  tlie  more  so 
as  it  ntTorded  a  rare  opportunity  of  ascerlaimug  by  inepectioD 
the  source  of  the  blood.  Ho  far  as  lie  know,  the  only  other  in- 
stance in  nbicb  there  had  been  a  eitnilnr  opportunity  waa  one 
recorded  by  Billard.  In  thnt  caae  also  the  eeurce  of  the  bleeding 
was  the  iuner  eurface  of  the  body  of  the  uterus.  The  reason  of 
the  rarity  of  potit-iiiartein  exauiinutioDa  was  that  in  the  groat 


nTKSirS   SHOWIKO    PUCRNTA    ?H£VtK. 


07 


nujurity  of  casva  this  «itcv-iioa  naa  quite  inaigni Scant.     Ko  was 
glwi  a  microscopic  eiuniaation  wa«  to  be  maAs. 

Dr.  Qkubhut  Spbkcicb  bad  only  seen  one  case  of  heemorrEiQge 
from  the  li»ing  iutaut'a  VAgina,  nQd  the  case  recovered.  He  had, 
howeTcr,  several  ttmeH  met  with  congestioD  of  the  uterine  mucous 
nvmbrnne  in  stiil-born  childrvn,  as  in  this  apecitnen.  He  had 
olio  aeoQ  bffimorrhaco  into  the  uiucoua  niembruue  of  the  body 
and  into  tlie  subpentoneal  tisoue  aroiiad  the  uterus. 


UTERUS  SHOWING  PLACENTA  PR.^\t:a. 

By  A.  H.  BouiNsoN,  M.D. 

(Ooinmunlcateil  fcy  C.  J.  CwLLiieowoitiH,  M.D.) 

i)R.  RoBiNsoH  exhibited  a  uterus  with  placenta  praavin, 
reuiored  from  thu  body  of  a  ^rl  aged  17,  wlio  liad 
been  ailing  for  several  days  but  concealed  her  condition 
from  her  friends.  On  the  day  of  her  death  she  was  found, 
early  in  the  morning't  coTered  with  blood,  but  denied  all 
kuowledge  of  ita  origin,  and  refused  to  be  exumined  hy  a 
mcdicul  man  called  iu  by  her  mistress.  8he  was  then 
rCEQOTOd  to  the  houeo  of  a  relative,  and  later  to  a  general 
hospital,  where  she  remained  some  time,  but  again  refust'd 
to  be  e.-camiued.  When  first  seon  iu  thooveuing  ahe  was 
perfectly  bl&uched,  there  was  no  pulse  at  either  wrist,  the 
heart-HonndH  were  feeble  and  faltering,  and  the  girl  was 
qaite  unconiicious.  A  va^lual  examinatloii  was  made,  and 
the  08  uteri  found  to  be  dilated  to  a  diameter  of  an  inch 
and  a  half.  Immedi)ttety  within  the  os  the  finger  eu- 
conntored  a  spongy  msds,  through  which  the  foetal  bead 
could  be  detected.  No  hDCmorrhago  was  now  present,  but 
the  girl's  clothing  was  saturated  with  bleed.  There  was  no 
Mcopo  of  amniotic  fluid,  the  membranes  being  intact,  and 
uterine  contraction  being  in  abeyance.  It  was  proposed 
to  perform  tmnsfusion,  but  before  that  could  be  effected 
the  heart  ceased  to  beat. 


68 


CTBBUS  SBOnma  FUC'KKTA   PK£TIA. 


A  necropsy  was  made  two  days  later,  when,  beyond  tlie 
most  marked  anffimia,  all  the  org&ns  appeared  perfectly 
normal.  Tbere  -waa  a  Bmall  amount  of  very  soft  black 
clot  ia  either  ventricle  of  the  heart.  Openings  were  made 
in  the  iliac  veins,  and  they  wore  f  onnd  empty.  On  opening 
the  abdomen  tlie  pregriant  nteras  wae  seen  to  extend  ap- 
nards  to  within  two  inches  of  the  ensiform  cartilage.  A 
vertical  incision  was  mudo  in  the  antenor  wall,  atid  a  fully 
developed  fcctng  extracted.  The  nteraa  being  then  re. 
moved  from  the  body,  it  was  fonnd  that  the  placental  at- 
tachment  occnpied  the  whole  of  the  auterior  wall,  ex« 
tending  from  within  an  inch  of  the  fundus  above  to  the  oa 
helow.  A  free  portion  of  its  circumference,  some  two 
inches  in  extent,  was  found  projecting  through  the  dilated 
OS.  On  this  free  edge  of  the  placenta  existed  a  rent 
an  inch  and  a  half  in  length,  the  mombrancs  being 
separated  for  some  diettince  aronnd.  Tbix)ugh  this  rent 
the  reticulated  Kubatanco  of  the  placeuta  could  be  eeeu,  and 
from  this  situation  prolonged  hsDmorrhage  had  doubtless 
talcen  place.  The  pelvis  was  well  formed,  and  no  impedi. 
ment  to  natural  labour  existed.  A  placenta  succenturiata 
was  present. 

The  specimen  was  referred  to  a  committee  consisting  of 
Drs.  PJayfair,  Cullingworbh,  and  Cliumpneya. 


60 


URETHRAL  DIVERTICULA. 
By  Amand  EoutHj  II. D, 
(iteceivtiii  NoTeuib«T  titb.  1880.) 

{Abstract.) 

TuuSE  cases  qE  urotiirarl  divtirticuU  aro  I'ola.led,  and  reEereucns 
to  otberB  made.  The  literature  on  iiiQ  subject,  though  datiug 
from  1847,  is  soaut}'  and  Bca-ttei-ed. 

Tbe  gynijiloms  are  progresaivtj  discomfort  and  frequt'iicy  o£ 
miotaritioii,  dysparemiia,  and  tit  fovmatioa  of  a  awellii^  which 
tiffitua  lit  the  vagiuad  ori&cu.  Pressure  upon  the  Hwclling 
causes  Ihin,  offensive,  irritating  I>U3  to  pass  into  and  out  of  the 
iirethni.  Cases  are  recorded  ehowiug  that  if  thetjc  divertii^uliL 
are  left  uotruatwl,  retrograde  changes  uccur  iiloug  the  urinary 
tract, 

The  phyiieal  eigits  are  (ineqniTOcal,  diCFeriug  on  the  one  hand 
from  disloi^atioii  of  the  nrcttra,  and  on  the  other  baud  fro^m 
■imple  dilatation  of  the  middle  third  of  the  inferior  wall 
(urethrowle). 

The  iliverticitluni  is  essoiitlally  a  urinary  poucli  or  cyst  com* 
municating  with  a  urethra  of  normal  calibre,  uaunUy  in  ila 
middle  third,  Ly  nu  orifice  relatively  narrow. 

The  stiolotfy  seema  to  be — 1.  CloBure  of  the  ducts  of  pre- 
exutiu);  urethral  glauds,  rvteutiuu-cynta  reituhin^.  Suppuration 
aod  tilc«ra.tiou  inl«  the  urethra  by  a,  small,  often  valvulur  liole 
follows,  anil  the  inflaininiiitioi]  ia  kept  up  by  urine  trickliog  iutu 
tbo  MM!  at  cac'h  act  of  micturition.  2.  Blood-cysts  which  have 
paued  through  Rimihir  changes.  'A.  Thia  formation  of  pseudo- 
cysts by  injury  to  the  urethral  floor  during  labour  or  inntru* 
muiitation. 

FregaaQ«y»  vitL  its  increased  local  actiritr,  seems  usuoily  to 


?0 


UKKTHKAL    DIVEItTICUIJk. 


iaduca  tlie  foriaatioii  o£  tbeee  cyete,  and  iiariilriUou  ai)]>u>irii  to 
be  often  the  immediate  cause  of  the  >'Uj>ture. 

The  treatment  is  injitiily  surgical.  1st.  Where  uretkriiU  nr 
c^stittB  exists,  the  cjfBt-w-a.ll  eliould  be  dissei-ted  out,  and  cut  off 
close  i^)  thi!  wrutbra,  Fiud  tlie  viigiiiul  wouml  Left  open  for  ilruiu- 
age.  2iid.  Wltere  the  vri-tt-arif  jjaeemi':!!  are  healthy  lUec^vst  should 
bo  diseeo-ted  out,  the  opening  into  the  urethm  enlarged  to  allow 
diainage,  and  the  vaginal  wound  at  once  closed.  In  either  caao 
the  ui'ine  should  be  drawn  off  till  union  is  assured. 


Three  eases  have  recently  come  under  observBtiou  at 
bbo  Hnmaritan  Free  Hospital,  and  as  tbej  appear  to  be 
not  infrequent,  and  yet  have  been  rarely  doscribed,  I  h&vo 
veiiturod  to  bring  thorn  before  this  Society,  hoping  to  hare 
light  thrown  opon  their  (etiology  and  proper  trcatmont. 

These  diverticula  occupy  the  arethro- vaginal  soptiini, 
and  commuuicato  with  a  urethra  of  tiormal  calibre  and 
position  by  a  small  opening  in  its  £aor. 

Roughly  speaking,  the  rixjviptoms  are  progressife  discom- 
fort and  fi-e(]Uency  of  micturition,  tlie  appearance  and 
growth  of  &  tender  lump  projecting  at  the  vaginal  orifice, 
passage  of  thin  irritating  pus,  cither  at  the  end  of  mic- 
turition or  on  pressure,  and  auoiier  or  later  cystitis,  &c. 

The  physical  tfujna  are  aB  follows : — Per  ■caffinara  n 
rounded,  teador,  touse  swellbg  is  found  in  the  urethru- 
vaginat  septum,  opposite  the  middle  third  of  the  urethra. 
Its  gmoothnesH  and  elastic  hardness  are  characteristic,  the 
rugHQ  of  the  mucous  membrane  over  it  being  oblitcirated. 
In  some  cases  the  mucous  membrane  move&  freely  over 
the  underlying  sac,  in  others  it  is  adherent  by  inflamma- 
tion. A  sound  paaaed  along  the  antenur  wall  of  the 
nrethra  goea  directly  into  the  bladder,  proving  that  the 
case  is  not  one  of  urethral  dislocation. 

As  proving  further  that  these  cases  are  not  simple  dila- 
tations of  the  middle  third  of  the  inferior  vrall  of  the  urothm 
(simple  urethrocele),  it  is  found  that  a  large-Bixed  sound 
will  not  enter  the  pouch,  but  will  pass  on  into  the  bladder, 
whereas  a  snoall  sound  or  probe  will  find  its  way  through 


IRAl  UIVSBTl 


71 


the  narrow  opening  (which  is  often  valvular),  if  it  be 
pftssed  along  the  posterior  wall  of  tlto  nrothra.  The  exact 
siee  of  the  opening  (usually  from  4  to  8  Euglish  cathoter] 
is  ancerlainGd  Ity  a.  gradaated  bulbous  sound. 

With  a  bougie  Ijing  in  the  urethm  the  sac  is  folt  to 
be  quite  distinct,  and  even  wLen  eniptioil  by  proseure  it 
remains  a  distinct  tLick-wallod  cyst.  Wbeu  full,  thcBO 
c^'sts  vary  in  aiKC  from  that  of  a  pea  to  that  of  a  heu'a  egg. 

After  being  emptied,  it  only  partially  rDliila  at  the  next 
act  of  mictarition,  taking  »is  or  eight  hours  to  becomo 
tcnso  by  exudation  from  ita  own  lining  inembrane. 


'^-■li. 


A 


The  first  of  llie  throe  cas&s  wbich  have  come  under  my 
notice  was  admitted  into  the  Sauiaritao.  Free  Hospital  by 


72 


ORKTSIUL  DlTXKTICOU. 


Ifr.   Malcolm,  under  tlie  care  of  Dr.  Percy  Boolton,  in 
February  last,  and  he  kaa  kindly  placed  hut  Dotes  at  uiy 

disposal. 

The  patient  was  a  Diarried  multipara,  aged  33,  whose 
cfaie£  pelvic  trouble  was  dysaria. 

Examination  revealed  granular  endocerricitis,  and  a 
urethral  divorticulum  the  size  of  a  marble.  Dr.  Bonlton 
treated  her  by  urethral  suppositories  of  lead  and  blsmnth, 
and  with  medicines,  for  three  weeks,  with  no  benefit,  and  on 
Hareh  1 1th  dissected  oat  the  cyst  -per  vngmam,  using  ouo 
^ut  sutnre  to  draw  the  vaginal  wound  together,  which  was 
iiot  otherwise  closed.  The  nrine  was  drawn  off  regolarly 
by  the  narae,  and  the  wound  had  granulated  up  in  seven 
da.ys,  by  which  time  no  pus  could  be  expressed  from,  the 
urethra.      She  is  now  quite  well,  all  cystitia  having  abated. 

The  sac,  when  removed,  had  a  rough  fibrous  capsule 
firmly  connected  with  the  adjacent  tissnes,  and  was  not  a 
true  cyst.  It  contained  dark  red,  fleshy  trabeculre,  sag- 
geeting  organised  blood-clot,  and  had  no  smooth  epithelial 
lining.  Dr.  Percy  Boultoa  thought  that  the  cyst  waa 
orig^inally  a  blood-cyst,  the  result  of  injury  during  partu- 
rition, and  that  connection  with  the  urethra  wns  dno  to 
suppuration,  Inflammation  being  subsequently  kept  up  by 
access  of  urine. 


Cask  2. —  h.  T — ,  aged  40,  married  twe)ity-two  yearsj 
ton  children,  last  fourteen  months  ago,  March  2l&t,  1889. 
Complained  of  dyspareunia  for  three  or  four  months,  and 
the  formation  of  a  patnfnl  lamp  at  the  vaginal  orifice. 
Had  iuflumuiatiou  following  pod&ltc  version  at  la^t  confine- 
ment,  but  beyond  pain  in  left  ovarian  region  noticed 
nothing  till  ten  inuuths  afterwards,  when  the  dyspareunia 
supervened.  On  e?;  ami  nation,  sigiie  nf  old  perimetritis 
were  present,  the  fundus  uteri  being  drawn  backwards  and 
to  the  left.  A  urethral  divorticuhim  the  sise  of  a  small 
walnut  was  found,  containing  extremely  offenaive  thin  pus, 
having  physical  signs  as  above  described.  On  Juno  7tb, 
Absisted  by  Dre.  Pi-tukett  and  Kutherfuord,  I  dissected  oat 


CRBTBRAL    DtVBRTICDU. 


73 


tto  Cyst,  wbicli  comtnutiicated  with  the  nrethra  by  two 
upeuings.  Those  were  united  along  the  Qoor  of  the  ure- 
Ihra,  the  vaginal  wound  closed  by  six  wire  suturctj,  and 
a  retaioinf^  catheter  iatrocluced. 

The  wonnd  beAleil,  but  a  pinhole  opening'  remained  at 
thcADtcrior  oiid  of  the  incision,  which,  however,  the  patient 
declared  cnnsed  her  no  inQouvcuioiJc<.',  and  shu  refuaod  to 
have  it  closed.  She  is  now  frt^e  from  all  pain  and  dis- 
comfort. 

Dr.  Ruthcrfoord  kindly  examined  the  sac  for  me,  and 
foand  it,  iiuliku  Dr.  Honlton's,  with  no  trabeculie  inside, 
ADd  with  a  smoothand  somewhat  glistening  out«ide  surface. 
Oa  aectioQ  it  was  mainly  couuectiYe  tiesue,  with  evidenco 
of  an  inflammatory  process  on  its  inner  side,  opou  which 
no  epithelinm  was  traced. 

Cabs  3.^ — M.  K — ,  aged  27,  married  three  years  and 
a  half ;  one  child,  two  years  and  a  half  ago. 

October  let,  1880. — CunipIninR  of  a  teuder  Bwtlliuf^  in 
tlie  front  passage  ;  pressure  upon  it  oauises  puiu  and  « 
discharge  of  irritating  matter ;  for  a  time,  however,  after 
the  sac  la  emptied  the  gnawiagj  throbbing  pain,  whicli  is 
otherwise  alwayii  present,  is  relieved.  She  had  (jnly 
noticed  Ihe  lamp  a  month,  and  says  it  followed  a  feverish 
attack,  with  ninch  local  pruritus  and  scalding  during  mictu- 
rition, which  latter  symptom  she  had  noticed  oS  aud  ou 
siooo  hor  confinement  two  aud  a  Imlf  years  ago. 

The  physical  signs  of  the  diverticulum  were  idcnticid 
with  those  already  described,  tho  opening  into  the  urethra 
being  about  the  size  of  a  14o.  0  catheter.  EtTorts 
were  made  to  apply  cauhiicR  to  this  eavity  by  dilating  the 
front,  part  of  the  urethra;  but,  tliis  failing,  !  operated  ns 
before,  removing,  however,  only  a  portion  of  the  cyst-wall. 
Thr  woman  was  directed  to  pass  water  in  the  gouupoctoral 
position,  and  left  the  hospital  cured  ou  the  twentielli  duy. 

But  few  rcfi'i-OLcos  uru  made  to  these  cases  in  litBratuit'. 

Parish*  of  Philadelphia  quotes  Cheron'sf  views,  and 

*  Ufejov***  *  Annual  of  Uiiivvnul  Mod.  Science*,'  lol.  tv,  1888,  p.  164. 
t  '  aat«lU!  dea  UApiUui,'  1SH7. 


74 


UKKTHIUI.    UlVKKl'ICUU. 


Jonks*  aJopla  tlieni,  consiilering  these  cases  to  be  variefciea 
of  urelhrucelo,  which  should  bo  divided  into  two  cIbescs  : 
1st,  simple  localised  dilfttntiou.of  tlie  middle  third  of  the 
inferior  wall  of  the  urethra;  and  2ud,  a  urinary  poucli 
cnmmunicatiug  with  a  urethra  of  norrniil  oahhrO  by  an 
orifice  relatively  narrow. 

These  three  observere  riow  these  diverticula  as  being — 
(I)  congenital;  (2)  caused  by  union  between  the  uretlnu 
nnd  n  pre-existing  non- con  genital  vaginal  cyst  ;  or  (3) 
determined  hy  a,  limited  touring  of  the  upethral  floor 
during  labour. 

In  1869  Dr.  Priestleyf  described  three  cases,  which  he 
thought  were  doc  to  distention  of  sebaceous  follicles. 
His  iirat  case,  and  possibly  Dr.  Hickinbothara's  described 
below,  are  the  only  recorded  examples  in  which  the  cytstH 
werediscoveredbeforeniptureintotheiirethra had  occurred. 
In  both  of  these  caaes,  howerer,  rupture  into  the  urethra 
occurred  during  the  impending  labour,  and  wo  may  assiirao 
that  thiB  13  the  coiiioion  history  iu  the  majority  of  these 
urethral  diverticnla.  Dr.  Prioatley'a  secioad  case  ia  also 
iutereating,  for  sebaceous  material  was  discovered  passing 
from  the  cjst.  The  opening  here  waa  in  the  middle  third  of 
the  urethra,  but  waa  evidently  valvular,  pressure  upon  tho 
cyat  causing  the  contents  to  pass  backwards  into  tho 
bladder.  WestJ  refers  his  readers  to  Huguier'aJ  work 
published  iu  IS17  for  notes  of  some  of  these  cases,  admit- 
ting,  however,  thiit  he  was  then  (I87i>)  not  familiar  with 
them  himself.  I  cannot  obtain  access  to  a  copy  oE 
Huguier's  paper. 

Dr.  HickinhotliamjII  of  Birmingham,  pablishes  a  very 
interefetiiig  case  which  occurred  in  a  uullipara,  daily  ox- 
poctiug  to  be  confined  of  her  first  child.  Cephalotripsy 
was  porfornied    because    of  a   rigidly  contractod  cervix, 

*  '  MiiDt/*  Sjgtcin  of  QyniDcolcg7,*  voL  II,  t&S8,  pp.  476,490. 

+  '  Brit.  Mod.  Jtmrn..'  186i).  vol.  i.  p.  6. 

t  Wnt  and  Duncan 'i '  DiioniM  of  Women,'  -Itli  edit.,  1879.  p.  029. 

S  •M<inoirBB<l«l«Sooitft^deCli!riirgie  de  ParU,' vol. i.  1847. pp.  326— 394. 

II  ■  lirlt.  Mv<i.  Jonrn.,  1882,  vol.  i,  p.  613. 


OKBIHEAL  DIVKiniCULA. 


75 


and  i)nhse<iiieiit  events  seemed  to  ^how  tlinl;  tLe  siiu 
then  ruptured  into  the  urethra.  At  all  events  tlie  cyst  at 
once  began  to  grow  mpidlj  aud  becoino  tender,  presuta- 
■bly  by  the  entrauce  of  urinu  causiu.^  more  mflaninuttion, 
aud  OQ  the  Icuth  duy  ahcv  labour  tho  c^'st  ruptatcd  also 
into  the  ragina.  At  a  subsequently  successful  oporntion  by 
LawsOD  Tnit,  tho  valvular  opening  into  thi?  urcthnt,  of  the 
aise  of  a  hempseed,  wns  well  sevn. 

Law&oa  Tait*  has  aleo  described  four  other  casus,  ouo 
in  1875,  the  others  in  1885,  He  thinks  these  cysts  may 
bo  congenital,  like  intestinal  diverticula,  or  the  result  of 
onion  between  the  urethra  and  a  cyst  of  pathological  origin. 

Englisch^t  of  Vienna,  has  seen  such  cysts  at  birth. 
Sautessont  arguiug  fi-om  a  case  eecu  in  1801,  thinks  they 
aro  duo  lo  injury  from  liibour,  or  to  clumsy  catlieterisa.- 
tion,  or  to  rupturo  of  simplu  vaginal  cysta. 

Duplay^  has  collected  six  cases,  one  of  which  (Gillette)  [| 
is  a  case  of  simple  iirfthrocele,  imd  two  others  doscribod 
by  Foueher^f  and  G.  Simon**  contain  no  nt'w  points. 

Very  few  modern  Knglish  text-books  of  gyniocology 
make  mention  of  these  cn8o<;,  and,  etrange  to  say,  ncitht-r 
Htnioei  iior  Skene  alludes  to  any  oilier  form  of  urethral 
dilatation  than  tho  siuiplu  urelhrooflc,  though  tlioy  cuIlx 
largely  into  genito-urinary  troubles,  one  case  of  peri- 
urethral abscess  bt-ing  mentioned  by  the  latter. 

Those  who  have  studied  tho  anatomy  of  the  urethra 
describe  many  varieties  of  glands,  closui'e  oi  whose  ducts 
Tvould  lead  t->  the  formation  of  rctention-cystu. 

Thus  Littre's  glands,  which  are  little  more  than  mucous 

uembrave  reduplicatioua,  are  doecribed  as  being    about 

twenty. five  in  number,  running  parallel  with  the  urothral 

■  ■  Un««t,'  1S76,  vol.  il,  p,  63S ;  and  ■  Brit.  Mcil.  Jonrn.,'  ISKS,  vol.  i, 

p.  982. 

■f  •  Wioner  muH.  PreHne,"  1881,  a.  599. 

J  'NoHlbktBitJ.  Arctir,'  vol.xvi,  IBS*. 

I  ■  Arcbiv.  Ucu.  du  Mo)..'  vol.  rii.  1880. 

II  'L'Uiilon  MWiwW  April  13lh.  1873. 
Y  '  Uonileiir  d<«  llflpitMni,'  I8S7,  p.  758. 
**  ■  llocualwUrift  fur  (lobnrtilc.,'  xxiii,  «.  215. 


76 


CtRSrBBlI,  ClTERTICCTLi.. 


floor,  and  opening  into  its  anterior  half  or  two  thirds  hy 
apertures  admitting  a  bristle. 

The  foIlieleB  of  Morgagni,  again,  aro  numerous  rnnall 
racemose  glands  opening  by  minute  ducts  at  right  angles 
to  the  uretliral  floor. 

Skeue^s*  ducts,  which  appear  to  be  the  efferent  canaU 
of  Mftx  Schiilier'st  glands,  are  two  in  number,  run  parallel 
to  the  anterior  third  or  half  of  the  floor  of  the  urethra, 
and  open  into  it  just  inside  the  meatus. 

Any  of  the  above  dncts  or  glands  maj  become  retention- 
cysts  by  closure  of  their  oritices  by  urethritia,  peri- 
■Brethritie,  or  even  accidental  plugging.  As  a  result  of 
Buppuration  or  rupture  the  cyst  then  opens  agniu  into  the 
urtithrn,  and  tho  iuOammatiou  is  kept  up  by  urino  fiudiug 
access  to  its  cavity  at  each  act  of  micturition,  and,  owing 
to  the  &ma!l  and  often  valvular  character  of  the  oponiug, 
the  distention  of  the  cavity  increases. 

As  these  diverticula  appear  to  be  always  opposite  the 
middle  third  of  the  urethra,  it  seems  improbable  that  they 
can  he  due  to  occlut^iou  and  distention  of  Hkeue's  ducts 
whicli  are  oppoaite  the  anterior  third,  unloss,  as  Mr.  Albau 
Dorant  suggests  in  his  reriew  of  Dlnnd  Suttou's^  work 
071  Gartuer's  duct,  Skene's  ducts  are  the  anterior  termina- 
tion of  Gartner's  dncts.  Though  Gartner's  dncts  are 
doubtless  reHpoiiaible  for  vaginal  cysts  near  the  cervix. 
Max  Schialler,t  Fischel,  Dohrn,  Rieder,  ||  all  deny  that  it 
ever  reaches  the  urethra.  Mas  Schuller*H  glands,  from 
which  Skene's  ducts  lead,  seem  to  he  the  most  likely 
urigin  of  these  retention-cysts. 

Blood-cysts,  as  in  Dr.  Percy  Boulton's  case,  may  be 
another  niodo  of  origin,  and  injury  to  the  urethral  floor 
an  BUggested  by  Cheron,  Saiiteasou,  and  others,  may  also 
be  occasionally  productive  of  a  paeudo-cyet,  whose  sym- 

•  'DiBeiMs  rf  Women,' ISStlj  ji.  516. 

i  '  Eiu  Deitriig  tat  AnBtoroio  <l<-r  ivpiblir.liPii  HaTUrUlirc,'  1883. 

J  •  Lond.  Mca.  Ilec,;  3H86,  p.  KIH. 

I  *  Amrricitn  Jnurii.  of  Olstutrics,'  vol.  xlll. 

II  •  Loud.  Med.  Ibio.,'  i88C,  }i.  8S, 


UB^THHAt   DIVEHTICDIA. 


77 


IB  and  pTiyBicnl  signs  may  greatly  resemble  tlioRO  of 
trco  retention -cysts. 

Pregnancy,  owing  to  greater  local  activity,  seems  to  be 
a  starting-point  for  the  formation  of  the  di7erticula,  and 
the  impending  labour  may  eufiice  to  canso  rupturo  into 
the  urethra  {Priestley's  and  liickiiibotham's  cases),  thas 
anticipating  the  slower  effects  of  a  subsci^uent  Guppuration. 

As  the  ietiology  of  tbese  trases  is  so  diEtinct  from  that 
of  simple  dilutation,  it  seems  a  pity  that  both  should  be 
grouped  under  the  one  word  nrethrocele. 

The  treatment  of  these  diverticula  has  been  varied.  Bo 
long  as  the  cysta  are  not  iD  conituuuicntlon  with  the 
opethra  thoy  can  he  treated  like  Bartholini's  reteutiou- 
cysta,  bat  when  nrine  is  obtaining  intermittent  entranco 
the  problem  is  more  difficult. 

Palliative  melhods  have  invariably  failed.  Mr.  Alban 
Dorou*  has  kindly  referred  uae  to  Saiitesson's.  eaao  wliiuh 
occurred  in  1861,  which  seems  not  to  have  been  described 
till  3884.t  It  occurred  in  a  widow,  whose  dysuria, 
prarituH,  and  vaginal  swelling  dated  from  a  con^nemeiit 
twelve  years  previously. 

The  phyeical  signs  differed  from  the  typical  iu  only  one 
respuct,  pressure  upon  the  swelling  i>er  viifjina»i,  cniising 
its  contents  to  go  backwards  into  the  bladder.  After 
fonr  years'  trial  of  palliative  treatment,  pressure,  caustics, 
SiC,  an  elliptical  piece  wan  cut  from  the  vagintil  wall,  and 
from  the  wall  of  tho  diveriiculumj  the  wound  beingunited 
by  sutures.  Some  sloughing  occurred,  the  wound  talcing 
five  weeks. to  heal,  and  four  years  afterwarcls  the  sac  again 
enlarged,  urethntis,  cystitis,  and  nephritis  supervened,  the 
patient  dying  six  years  after  the  failure  of  the  first  ope- 
ration.  Santeaaon  now  states,  after  tweuty-thr^e  years' 
interval,  without  apparently  meeting  with  another  case, 
fchat  in  any  future  case  he  wonld  remove  the  wholo  diver- 
ticuluta,  suture  the  margin  of   the  wound,  and   keep  a 

•  '  LoiiJ.  M*^.  Rw.,'  1885,  p.  08. 

f  '  Norditkt  mti,  Atubiv,'  voL  sri,  ISIiH  j  '  Schmidl'a  J«lir1>ucli«r,'  cciii, 
]MTi  ia,  art,  479. 


78 


URETHRAL   niVKBTIC 


cathe-ter  in  intu  till  union  was  complete;  and  t!iis  metliod 
was  adopted  with  success  by  Lawson  Teit  in  his  four 
cages.  In  1868  Dr.  Priestley,*  in  conRulta.tion  with  Sir 
James  Paget  and  Sir  Sfiencer  Wells,  proposeil  to  pass  a 
seton  through  a  urethriil  diTerticuluni  for  its  ohliteration, 
and.  If  this  proved  iueffectual,  to  lay  it  open  per  iwginnm. 
The  patient,  liowevei",  sliraiik  from  any  surgical  inter- 
ference, and  her  subsequent  history  is  unknown. 

Cheron,t  in  1887,  advocated  Blitiing'  up  the  urethra 
from  the  orifice  of  conimuDication  to  the  meatus,  and  the 
one  case  ho  saw  and  thus  treated  wan  cured.  From  the 
experience  brought  by  all  these  cases  it  seems  that  there 
are  two  ways  of  dealing  surgically  with  them,  and  that 
if  we  desire  to  prevent  such  retrogrBBsive  changes  aa 
occurred  in  Sontesiion'a  case,  we  should  promptly  adopt 
ouo  OP  other,  or  some  operation. 

1st.  Where  uruthritis  or  cystitia  already  exists  the  cyst- 
wall  Hluiuld  be  dissected  out,  and  the  vaginal  wound  left 
wholly  or  partly  unclosed  to  allow  of  free  drainage.  In 
the  rare  event  of  niiiou  not  occurring,  a  sccoudary  ope- 
rution  would  bo  roquirud  later.  This  was  Df.  Boulton'a 
method  of  operating  (Case  1], 

2ud.  Where  the  urine  is  normal,  and  the  urinary  pas- 
sages are  healthy,  tlie  cyst  should  be  dissected  out,  tlio 
opening  into  the  urethra  enlarged  to  allow  of  urethral 
(Irflinage,  and  the  vaginal  wound  at  once  closed  with  wire 
sutures,  which  should  not  enter  the  urethra  itself. 

Till  union  is  caraplete,  the  vngiua  should  be  kept  asaptie 
as  far  as  possible,  aud  tht)  «rine  should  be  drawn  off 
either  ut  rifgular  intervals  ur  by  a  retaining  cathettr;  or, 
as  was  adopted  in  my  second  case,  the  woman  may  bo  told 
to  pass  water  in  the  geuupectoral  position. 

In  dissecting  out  the  diverticulum  the  presence  of  a 
l&rge  bougie  in  the  urethra  ia  Lelpfol,  and  the  contents 
of  the  cyst  should  not  be  pressed  out  lest  it  become  tiaccid. 
Before  the  sac  is  separated  from  the  urethra  it  niay  bo 

•  ■  Brit.  UtHl.  Joorn.,'  Ifm,  vol.  i,  p.  a 
t  '  Cla»ttc  «1>-it  HOpiUvV  lsa7i 


QRI3THRAL    DIVERTICCIA. 


79 


JnOlMd,  and  after  its    contents  have   escaped    the   Rtnall 
opening  into  tbe  urethra  can  bo  woH  seen. 

In  my  second  ciise  I  rumoveil  only  s,  portion  of  the  sac  ; 
but  though  the  cure  ia  complete,  it  seems  safer  to  disaect 
oBt  the  whole  cyst-wall. 


Dr.  BSAXTOK  Hicsa  uid  that  iu  tlio  couruu  of  hit  practice  he 
had  Been  five  coac^i  of  Lhe  kind  ;  iu  one  tlie  cavily  was  lilled  witb. 
pboBpbatic  concretions.  Kw  had  truuted  Ihem  6y  vpaaing  them 
Jreely  from  the  vagina,  keeping  the  openiug  free  till  ihe  urethral 
opentng  closi^d,  which  he  fouad  to  occur  at'lvr  a  little  tiiat*.  Hs 
thought,  however,  that  tho  [>!Bn  recouiuioinled  by  the  author  u£ 
thp  p&per  was  more  precise. 

Dr.  Uesmav  thought  that  the  title  of  the  paper  would  hare 
more  currectly  indicated  iu  contentti  haii  it  been  ^' injiamai 
urothral  divtrticala."  These  diverticula,  evea  when  convortod 
into  rirtentioii-c>(ttB  by  cloeure  of  their  ducts,  caused  no  ayni- 
ptomB  nuch  as  Dr.  Kouth  hitd  described  until  they  became 
iBBatned.  He  thought  thut  cysts  dischurging  fatty  matter  and 
opeuiuj;  into  the  urethra  were  probably  dermuid.  ]  a  the  '  'i'niuci> 
actions  '  for  1S80  h«  had  described  a  case  very  similar  to  uue  of 
thoia  related  in  the  present  paper,  lie  had  reported  that  citao 
under  the  title  "  abevcea  of  tlie  ureliira,"  a  term  which  he  hud 
uaed  a»  not  implying  a]iy  theu'ry  of  uausation,  The  interior  of 
the  cavity  iu  tiiat  case  uatt  ra;;gcd,  nut  smouth,  Lilce  a  cjat-wall. 
Tliis  waa  also  observed  in  oncol  Dr.  Ituuth'H  casea.  Dr.  Kcnnan 
had  nuggested  that  the  coudittoa  might  have  been  a  result,  of 
ehrouic  cougcxtiua  of  the  urethra,  such  hb  had  heeii  deacrjbed  by 
Sir  Charles  Clarke,  and  after  hiui  by  Dr.  West.  This  condition 
was  especially  freguoot  iu  preguoucy,  and  he  ubaerved  that 
Dr.  l£outh  had  commented  un  the  Irecjitericy  with  whieh  the 
suppuration  opptared  to  have  been  induced  by  pregnancy  aud 
labour.  Dr.  Kouth  attributed  it  tu  iujury  duriug  inhour,  uudhu 
(Dr.  Herman)  thought  the  prcHxure  Huistaiiied  duriug  delivery 
would  be  more  likely  to  briug  about  uuppurntiou  if  the  cougett- 
tion  di-ecribed  by  Sir  C.  Clarke  had  been  present  befuredclivery. 
The  word  "diverticulum"  was  usually  employed  to  denote  a 
communicating  cavity  du6  to  a  cougeuitaL  peculiarity  of  struo- 
tarf,  and  iu  thai  sense  of  tho  word  tlie  cases  of  abscess  opening 
iute  the  urethra,  to  the  description  of  which  in  the  abxtroct  tho 
figs,  i!  aod  '6  wto  pretiied,  were  not  true  diverticula.  They 
could  only  be  called  diverticula  in  tlie  same  aeuse  aa  a  pulvio 
absoeas  opening  into  the  rectum  could  be  called  a  rectal  diverti- 
calum.  Dr.  Houth's  paper  was  a  valuable  eouCribuLiun  to  our 
ItDowledge  of  the  subject. 


80 


USSTRRAL    DTVERTICUL&. 


Dr.  M.  HAMnFiELD-JoNES  Jwclt  upoa  one  method  in  wMcIi 
those  uruthnil  diverticula,  might  originate.  Ue  hnd  sIiowq  at  u  j}r«- 
viouB  meeting  oftho  Society  two  small  cyata  which  lie  had  removed 
from  ibe  vagina  of  a  patient  who  had  been  Bent  to  bim  complain- 
ing of  a  cyatocele.  The  tno  ey&ta  wore  Hitunteii  bennatli  tho 
floor  of  the  urethra,  and  during  the  procesa  of  removal  were 
found  to  h«  HO  clone  to  the  floor  of  that  canal  that  it  had  been 
difScult  to  avoid  woundmg  the  urethra,  iu  the  operation.  Had 
they  not  been  reniuved,  these  cyatn  would  probably  have  opened 
into  the  I'tinal  of  the  urethra  as  their  growth  progressed,  or  if  a 
labour  bud  supervened  they  would  probably  have  suppurated 
from  proseure  nod  eHliiblished  a  cemuiuiiicatiuu  with  the  urethra. 
Id  eitlier  caae  a  ao-Called  urethral  diverticulum  nould  have  beeu 
formed,  and,  by  the  irritation  caused  through  the  adtnissioa  of 
uiine,  hftve  given  rise  to  syuiptoius  rendering  an  operation 
ueceasary. 

Mr.  Alban  Doran  believed  that  the  cotidition  deacribed  by 
Dr.  Amand  Bouth  could  well  arlBs  Irom  one  of  at  leaat  two 
soureea.  The  diverticulum  might  origioa-tep  in  a  cyst  or  in  eome 
chauge  in  a  gland  or  ila  obstructed  duct;,  fo-r  c-yBta  certainly 
developed  near  the  urethra,  and  glanda  undoubtedly  existed  in 
the  miicous  membrane  of  tbnt  canal-  On  the  other  hand,  the 
position  gf  tbe  urethra  aud  the  uhyslcal  fonditione  tc  which  it 
was  exposed  allowed  of  protrusioiis  uf  the  mucous  ineinbrane. 
In  order  to  be  certain  about  the  prcciBe  character  of  urethra! 
cyotB  and  gUude,  tho  adult  urethra  should  be  studied  micro- 
BCflpically.  Hitherto  writers  on  those  strnfturcs  hnd  relied  too 
much  on  liomologios,  and  on  puthologieul  and  rnorpboLooical 
theories.  Qucstiutis  about  Gartner's  ducts  and  glands  Wliich 
uiiglit  be  homologuea  of  tho  vesiciilffi  Beniiiialna  in  the  male  wore 
very  interesting,  but  not  to  tbe  purpose  in  the  present  diai-uft. 
eion.  On  tbe  ether  hand,  a  urethral  diverticulum  niiglit  have 
been  a  diverbicalum  from  the  lirat  and  never  a  cyot.  It  then 
reeembled  the  "  distention  diverticula"  of  the  email  iiitott- 
tiue  to  which  Mr.  Doran  referred  in  a  paper  in  the  '  'IVansac- 
tiona  of  iho  PathologicaE  8oi'ietyof  London.'  vol.  xxix,  p.  122 
(ece  lii.  Hilton  F;igge,  ibid.,  vol.  xxvii,  p.  146).  Poucbea  of 
mucoUB  membrane  prutrudicd  between  deEiciencies  in  the  muB< 
cular  coat  of  the  intestine.  Tho  urethru  was  etill  inure  liable 
to  an  homologous  condition,  since  its  niuoculir  coat  might  be 
damaged  in  the  second  Btnge  of  labour. 

Dr.  Ama:(ii  Boi^tH  euid,  in  reply,  that  he  could  find  no  word 
better  able  to  oxpreatt  all  the  forms  of  these  cyHts  than 
"  diverticulum  ;"  and,  in  reply  to  Dr.  Hennao,  he  thought  tb&t 
the  moment  urine  obtained  access  to  the  cyst  inHammatioa 
ensued.  Perhapa  other  origins  of  these  cyats  were  from  a  sub^ 
scrouH  follicle  at  from  a  dermoid  cyat,  aa  had  been  stated  bv  Dr. 
Priestley,    lie  thanked  Dr.  BraxtoD  Uiuks  and  Dr.  Uaudfield* 


UB1THIU.L   DIVKRTICDLA.  81 

Jones  for  their  notes  and  early  history  of  other  cases.  He  had 
operated  on  a  fourth  case  Buccessfully  since  the  paper  was  sent 
in,  in  which  cystitis  and  pyelitis  bad  already  occurred.  In  this 
case,  owinff  to  the  purulent  urine,  be  had  only  partially  closed 
the  vaginal  wound,  so  as  to  allow  free  vaginal  drainage,  and  the 
wound  was  quite  closed  in  ten  days. 


VOL.  IXXIl.  6 


Anncai,  Mbetino. 

Thb  audited  balauoe-eheet  of  tlio Treasurer  (Dr.Hermon) 
wita  road. 

It  w»s  proposed  by  Dr.  J.  Wait  Black,  setoutlfd  hy 
Dr.  BuxALL,  audcarvied  iiimuiinously — "  That  tlie  audited 
report  of  the  Treasurer  jnst  rend  be  received,  adopted, 
uud  priuted  in  tLe  next  voliitue  of  t!ie  '  Transactions.'  " 

TIio  report  of  the  Honorary  Librarian  (Dr.  Horrccka) 
ivas  then  re&d. 

Report  of  the  Honorary  Librarian  ftrr  1889. 

"  Duriug  tlio  paet  year  134  volumes  have  been  uddcd 
to  the  Library.  These  are  mndo  up  of  45  booka  and  15 
tracts  (odd  vol.)  given,  and  20  books  and  30  tracts  (two 
vols.}  bought.  The  penoJicaia  make  57  volumes.  The 
total  number  of  books  iu  the  Library  now  BmountH  to 
4138, 

"PiTIK  HOEROCKS." 

Dr.  Dbakton  Hicks,  after  congratulating  the  llonorary 
Librarian  on  hia  report,  expressed  n  hope  that  the  Fellows 
would  koop  in  viow  tho  collection  of  engraved  portrait-s  of 
past  0bstctriciaii8j  iiud  add  to  it  as  opportunities occun-od. 
It  wus  moved  by  Dp.  Hicks,  seconded  by  Dr.  Montagu 
Hamdfikld-Jones,  and  earned — "That  the  report  of  tlio 
Honorary  Libriiriau  be  receivtid,  adopted,  and  printed  in 
the  *  Transactions.' " 


The  report  of  the  Chairman  of  the  Board  for  the 
Kxamination  of  Midwives  (Dr.  J.  Wutb  Black)  was  then 
read. 


ALtEKATlON  OV  hLVTB. 


lUport  of  the  Chairm-an  of  the  Board  for  the  ExatninaLiMt 
of  Midwive.a, 

"The  candidates  for  the  diploma  of  tho  Society  still 
continue  to  iucroQse  in  niimber  everyyear.  In  188!)  they 
aiuountod  to  170,  of  wliom  l-tS  pasapd,  27  failed,  including 
2  Bbsent,  or  158  pec  cent.  In  1888  there  were  149  candi- 
dates  with  14'7  per  cent,  of  rejections.  The  total  number 
examined  since  1872,  when  the  Midwivcs'  Diploma  was 
first  instituted,  np  to  the  end  of  1889  has  been  il2U.  Of 
(hesei  761  have  obtained  the  diploma  and  154  have  failed, 
or  16'6  per  cent. 

"J.  Will  Black, 

"  Chairman." 

It  was  propoaod  by  Dr.  Wimiam  Duncan,  seconded  by 
Dr.  Cleveland,  and  carried  "cm.  con.  "That  tlio  report  of 
tho  Chairman  of  the  Board  for  the  Examination  of  Mid- 
'Wivee  be  received,  adopted,  and  printod  in  the  '  Traueac- 
tious,'  and  that  the  best  thanks  of  the  meeting  be  given 
to  Dr,  Black." 

The  following  alteration  iu  the  Daws  was  put  froai  the 
Chair  and  carried  ; — 

Caf.  V. — Of  the  contribotions  or  Fellows.  In  Sect.  3, 
itmtead  of  "  Fellows  wishing  to  compound  for  their  Aunual 
Subscriptions  may  pay  a  Composition  Fee  of  Ten  Guineas," 
to  sulslHfite  "  Ftillowa  wishing  to  compound  for  their 
Annual  Subscriptions  may  pay  on  adtniasiou  a  Coraposi- 
tiou  Fee  of  Fifteen  Guineas  ;  after  Ten  Annual  Payments, 
Ten  Guineas;  or  after  Twenty  Auaual  Payment*,  Fivo 
Guineas." 


The  result  of  the  BuUot,  the  ticruLineers  having  pre- 
sented this  report,  watt  declared  by  the  President  as 
follows : 


OfflCEBS   AHD   COCNCIt. 


85 


Trefn3enL — Alfreil  Lewis  Galabin,  M.A.,  M.D. 

Tice-PifJiideittg. — Percy  Boulton,  M.D. ;  Francis  Henry 
Chanipneys,  M.A.,  M.D.  ;  Arthur  Guy  Eltirgton  (Deputy 
Sorgeon-General)  ;  Thomas  Crawford  Hnycs,  M.D. ;  Evau 
Jones  (Aberdare)  ;  A.  E.  Aust  Lawrence,  M.D,  (Clifton). 

Treaatirer. — G.  Ernest  Herman,  M.B. 

ChairmoK  of  Hie  Hoard/or  the  Examinalioit  of  Mtdzoivcs, 
— James  Watt  Blaek,  M.D. 

Honorary  Seerelfi-nes. — Alban  Doran ;  Peter  Horrocks, 
M.D. 

Honorary  lAbrarian. — William  Duncan,  M.D- 

Other  Mfmbem  of  Council. — TTionias  Edward  BowTcett  ; 
Hobertnoxall,  M.D.  ;  Albert  Clmrles  Butler-Smythe  ;  W. 
Radford  Dakin,  M.D.  ;  S,  Houston  Davson,  M.D. ;  Henry 
Gervis,  M.D. ;  Robert  Alexander  Gibbons,  M.D. ;  Frede- 
rick B.  Hiillowes  (Redhill)  ;  Edwin  Hollings,  M.D.  ; 
Henry  Ambrose  Lediard,  M.D.  [Carlisle)  ;  Heury  Colley 
March,  M.D.  (Roclidale)  ;  Richard  Henry  Milson,  M.D.  ; 
Oliver  Cftlley  Maurice  (Reading)  ;  Thomas  Cargill  Nesham, 
M.D.  (Newcnstle-on-Tync) ;  Edward  Jfttnes  Nix,  M.D.  ; 
John  Bnptistc  Potter,  M.D. ;  Herbert  E.  Spencer,  M.D. ; 
Harry  Speakman  Webb  (Welwyn). 


The  President  tlien  delirered  the  Annaat  Address. 


ANNUAL  ADDRESS. 

QsHTLEHENf — TIiB  past  je&T  h&s  heou  oyontful  in  the 
history  of  oar  Society  by  the  termination,  in  it  of  out  long- 
aUnding  custom  of  holJing  oar  meetings  in  the  rooms  of 
the  Royal  Medioal  and  CUiirtirgical  Society  at  53,  Bprnera 
Street.  That  we  are  still  passing  throngh  a  tmnaition 
period  is  ehown  by  the  fact  of  our  being  now  present  in 
^^his  Library  to  hold  our  Annual  Meetiiig. 

It  is  now  eight  years  since  the  Library  oE  our  Society 
was  removed  from  the  roams  formerly  occupied  in  Regent 
Street  to  thoae  in  which  it  now  is.  Ky  that  removal  we 
gained  more  spacious  and  coarcnient  accommodation  for 
our  hookS]  and  we  gained  also  the  advantage  of  having 
our  library  next  door  to  our  place  of  meeting,  and  to  tiu 
library  of  the  Royal  Medical  and  Chirurgical  Society. 
We  did  not  gain  anothoi"  advantage  which  at  the  time  we 
had  stipiilatud  for,  namely  Mocarity  of  tenure  undera  loaso. 
The  originBl  holder  of  the  ground  lease  having  failed  to 
fulfil  his  engagements  to  hia  landlord,  the  lease  for  which 
we  had  made  a  formal  agreement  was  never  granted  ub, 
and  from  t!mt  time  to  this  we  have  been  annual  tenants 
merely. 

It  was  under  these  circumstances  that,  through  the 
removal  of  tha  Royal  Medical  and  Chirurgical  Society  to 
Hanover  Square,  we  lost  the  coiiveniouce  of  the  proximity 
of  the  two  hooses.  In  following  that  Society  to  its  new 
abode,  so  far  an  regards  tho  use  of  the  meeting-room,  it 
was  evident  that  wo  should  giiin  a  great  advantage  if  wc 
could  obtain  also  a  library  in  tLo  same  house,  and  thus 
secure  the  honefila  of  that  more  favoured  locality,  both  for 
our  meetings  and  for  our  library.  Your  Council  has  been 
for  some  time  engaged  in  negotiations  for  this  object  with 
the  Royal  Medical  and  Chirurgical  Society,  and  I  have  the 


A!iSUAL   ASDRISS. 


87 


pleasare  to  aunonuco  tliat  these  negotiations  are  now  prae- 
tically  complete^  some  minor  ]ega]  details  only  not  being 
finally  decided.  Wa  may  cheerfully  bear,  therefore, 
whatever  inconvenience  may  have  been  felt  in  holding  the 
present  and  the  last  few  meetings  in  tliis  library,  in  look* 
ing  forward  to  the  permanent  gain  which  is  shortly  to 
follow, 

Wc  shall,  in  future,  have  a  larger  and  lietter  arranged 
meeting-room  than  formerly,  as  well  as  a  commodions 
room  adjoining  for  exhiljition  of  Bpecimens.  Wo  shall 
have  two  good  rooms  on  the  first  floor  for  our  library, 
which  will  afford  greater  space  for  our  books  than  wo  at 
pre^nt  possess,  and  so  allow  room  for  progressive  expan- 
sion. Arrangements  have  also  been  made  for  the  use, 
in  addition,  of  a  waiting-room  for  tlte  midwives  at  our 
qnarterly  midwives'  esauiinationa,  at  which,  owing  to  the 
aoDually  increasing  aumbt;r  whicli  present  themeelves, 
mnch  iciconvonieDCC  has  been  feic  in  our  present  premises. 
We  ehall  have,  in  addition,  tho  EDcurity  o£  a  twenty-one 
years'  lease,  and  we  shall  have  the  benefit  of  the  electric 
light,  both  for  the  niocting-rooni  iind  for  the  library,  and 
thus  shall  be  exempt  in  fntiiro  from  the  injurious  effect  of 
gas  upon  oar  books.  Naturally  gome  increase  of  rental 
is  attendant  upon  all  these  advuutages,  and  the  removal 
to  a  more  expensive  locality  ;  but  it  is  an  increase  which, 
in  tlie  opinion  oE  the  Council,  the  prosperity  of  the  Society 
will  enable  it  to  bear.  I  may  justly  congratulate  the 
Society  upon  the  prospect  before  it,  which,  I  feel  sure, 
will  be  the  inauguration  of  an  era  of  prosperity  yet  greater 
tliuu  before. 

In  other  respects  also  I  have  to  congratulate  yoa  upon 
tho  Bfttiefaotopy  condition  of  year  Society.  An  annually 
increasing  number  of  candidates  present  theiuBelvea  for 
our  diploma  for  midwives.  During  tho  past  year  the 
number  has  been  170,  of  whom  148  pnsscd  ;  and  the  total 
number  on  the  register  is  now  761. 

The  Society  haa  thus  boeu  doing  an  important  work  in 
this  respect.     But  it  haa  always  boeu  in  favour  of  legiala- 


88 


ANKVlir.    AUDKKS8. 


lion  to  establ!sli  a  register  of  miilwives,  an<l  Kui(al>te  Ifsl 
Biamiaationa  throughout  the  country.  In  default  of  iegia- 
lation,  which  lack  of  time  for  useful  work  in  Parliament 
has  httlierto  preventejj  it  lias  been  proposed  of  late  to 
estabiieh  a  volantary  register  for  midwirea,  in  asBOciation 
with  a  similar  register  for  nurses.  It  is  obTions  that  a 
Tolnntary  register  might  fail  to  n  great  extent  tfl  secure 
tha  benefitH  which  would  follow  from  a  compulsory  owe, 
since  it  would  become  futile  if  any  large  propoption  of  the 
midwivcs  did  not  choose  to  register  theineelvea.  More- 
over, the  midwivea  themselveSj  so  far  as  tliey  are  repre- 
Bonted  by  the  Midwivea'  Institute,  the  members  of  which 
are  holders  of  the  diploma  of  our  Society,  prefer  t«  staud 
by  themselves,  and  decline  to  be  aesocinted  with  mirsc«. 
I  ara  glad  to  say,  therefore,  that  this  year  there  is  again 
a  po»Bibility  at  auy  rate  of  legislation,  since  a  bill  is  to 
bo  introduced  into  Parliament  by  Mr.  H.  F.  Pease, foUowinff 
in  the  main  the  lines  of  the  draft  bill  drawn  up  some  years 
ago  by  the  Obstetrical  Society,  but  giving  to  ihe  new 
County  Councils  the  duty  of  appointing  tho  examining 
bodies.  The  project  lias  received  the  approval  uf  the 
General  Mudical  Council. 

The  number  of  volumes  in  the  Library  amounts  now  to 
4138^  134  having  been  added  during  the  year,  of  which 
4G  were  donations. 

The  eatiafactory  financial  position  of  the  Society  is  shown 
by  the  Treasurer's  balance-sheet,  which  Las  boon  rend. 
Tho  surplus  for  the  year  is  not,  indeed,  so  great  as  on  some 
previous  occasions,  but  even  this  is  itself  a  testimony  to 
our  sound  position ;  for  the  reason  of  it  is  that  your 
Council  has  thought  tlie  funds  of  the  Society  to  bo  in  &o 
favourable  a  condition  that  it  could  devote  the  main  part 
of  tho  fees  paid  by  midwives  for  examination  to  givingan 
honorarium  to  the  examiners,  who  for  many  years  had 
performed  their  labours  gratuitously,  and  whose  work  waa 
becoming  every  year  more  arduous,  owing  to  the  multipli- 
cation of  candidates. 

The  total  number  of  Fellows  on  December  Slstwas  738. 


AinnT4L  ADDRB8B. 


80 


Thirty-eiglit  new  Fellows  were  elected  during  tlie  year, 
wliile  37  were  lost  hy  resignation  and  crasnre,  aud  9  by 
dentb.  In  view  of  this  ver)'  slight  decrease  In  our  nuin- 
l>er8,  which  has  octniTed  both  in  the  last  year  nnd  in  the  one 
prccediugTi  it  mny  not  ^^  out  o£  place  to  Guggeat  to  nil  our 
Fellows  that  ct  large  influx  of  new  Fellows,  such  as  has,  I 
belic'i'e,  already  commoncod  to  the  Royal  Medical  and 
Chirurpcal  Society,  would  be  no  inappropriate  accom- 
pnniment  to  our  removal  into  a  moi-e  favoured  locality,  and 
the  consecjueTit  increase  of  our  rental. 

Charles  Davidson,  M.D.  St.  Andrews,  F.B.C.S.Edln., 
L.K.Q.C.IM..  died  on  January  li^th,  at  the  age  ot  forty- 
seven  years.  He  was  brought  up,  Rltliougli  not  bom,  in 
the  Orkney  Islnnds.  He  studied  at  Kdiuburg-h  University, 
and  there  tonk  the  degree  of  F.R.C.S.Edin.  He  then  pro- 
ceeded to  Loiidun,  where  liis  first  appointuieitt  was  that  of 
Medical  OfHcer  to  Bethnnl  House  Aeylum,  After  a  time 
his  be«lth  gave  way;  ho  resigned  that  appointment,  and 
Bpont  some  time  in  travelling.  Having  regained  his  health, 
he  settled  in  Caasland  Rond,  Sontli  Hackney,  where  ho 
speut  about  twenty  years  in  quiet,  unostentatious  hard 
work.  He  was  elected  a  Fellow  of  the  Society  in  18P3. 
He  was  a  member  of  the  Council  of  the  Metropolitan 
Coonties  Branch  of  the  Hritish  Medical  Association,  and 
took  an  active  interest  in  establishing  the  East  Loudon 
and  South  Essex  division  of  the  branch.  He  also  held 
the  office  of  Surgeon  to  the  7th  Middlesex  Artillery 
Volantecr  Brigade. 

Although  not  in  rohust  health  for  the  last  three  years. 
Dr.  Davidson  teemed  fairly  well  and  in  good  spirits,  and 
in  the  summer  of  18^8  enjoyed  a  holiday  in  the  Voagee. 
Returning  to  Ijondon  he  resumed  active  work,  but  met 
with  a  chill  which  cnt  him  oft  after  a  few  days*  illnosg. 

Dr.  Davidson  was  a  man  of  wide  culture;  his  opinion 
was  worth  having  on  the  style  of  a  hook,  the  ugefulneas 
ot  an  instrnmont,  or  the  choice  of  a  picture.  His  profes- 
sional attainments  were  groat.  Perhaps  he  excelled  most 
OS  a  therapeutist;  his  knowledge  of  drnga  was  extensive 


90 


ANNrAL  ADDBES3. 


I 
I 


and  precise.  His  code  of  profeBsional  honoar  was  Iilgl), 
aud  he  acted  up  to  it.  Hia  keeu  iutellect  vras  guided  by 
a.  warcQ  heart,  and  bngbteued  by  a  maiiaer  geuial  u» 
Hiimmer. 

Hunter  Jackaon  Barron,  M.D.,C.M.Ediu.,L.R.C.r.Lond., 
M.R.C.S.Eng.,,  died  on  February  0th,  at  th&  early  age  of 
thirty-one.  He  was  educated  at  the  Cliarterhoiige  School. 
He  very  early  pvinced  hie  love  for  natural  history  purauits, 
and  had  made  his  choice  of  the  profession  of  medicine. 
He  became  a  stmlent  at  St.  Thomss'g  Hospital,  aud  ma- 
triculated at  the  Loudou  University  ;  but  having  formed 
the  opinion  that  the  oonree  was  too  protracted,  he  went  to 
Edinburgh.  He  there  took  the  decrees  of  M.B.  and  CM. 
ill  18H3,  and  two  years  later  thut  of  M.D.  While  at 
Edinburgh,  a  patieiut  in  the  hospital  requiring  it,  be  volao- 
teered  to  supply  thu  necessapy  blood  for  transfuaion. 

Dr.  Biirron  paid  especial  attention  to  the  study  of 
zoology,  taking  Sir  Wyville  Thomson's  silver  mednl  for 
pi-actioa]  zoology  at  Edinburgh  in  1879,  and  bt-ing  an 
occasional  coatrihutor  to  the  Britiah  Museum  of  speciuiena 
of  British  Mollusca,  of  which  he  had  himself  a.  large  ani 
beautiful  collection.  He  was  also  Pattiaon  Medallist 
in  medicine  at  Edinburgh,  and  became  a  Fellow  of  ihe 
Linnican  Society,  lie  was  elected  a  Fellow  of  this  Society 
in  188(i,  having  cBlabliahed  himself  in  praclicoin  Fiuchley 
in  IB85. 

Dr.  Barron  was  distinguished  in  athletics  as  well  ns  in 
science.  Ho  had  been  a  good  swimmer  from  a  very  early 
age,  and  waa  well  kuuwn  in  the  Bwimining  world  ns  a  first- 
rate  amateur  in  the  art.  Ho  took  very  great  interest  in  chia 
pursuit,  and  did  all  that  hi*  possibly  could  to  encourage 
it.  He  had  been  captain  of  the  Otter  Swimming  Club, 
aud  also  hon.  Bccretary  of  the  iSwimming  Associution  of 
Groat  Britaiu  from  1H80  to  1883,  and  president  in  188-i 
and  1 885,  doing  much  in  both  ihoac  capacities  iuv  the  cu- 
conragomcnt  of  the  art.  Ou  hi»  rufiigning  the  position  of 
president  ia  1980,  ho  was  pi-cscnted  by  the  delegatos  o£ 
the  Aasociation  with  a  handsome  testiiuouial,  in  npprocia- 


AHNVAL    ADDKB8S. 


fll 


la  efforts  to  promote  btiiI  populnrisi'  swimming' 
geuerally.  Portraits  and  momoirB  o£  him  as  an  amateur 
svimioer  appeared  in  the  '  Bicycliog  iind  Athletic  Journal ' 
of  November,  1880,  and  tlie  '  Sporting  MiiTor '  o£  May, 
1882,  and  lie  had  Eroia  time  to  time  contributed  articlciS  ou 
hia  favourito  poatime  to  the '  Field  '  and  other  papers.  His 
lore  for  swimming-  as  a  sport  was  Bubordinalo,  howoveTj  to 
his  desire  to  eucouraf^e  it  as  a  health-giving,  life-saving- 
art,  and  he  was  never  more  pleased  than  when  lecturing 
to  »  school  or  institute  on  the  Kuhject,  or  framing  rules 
for  their  guidance  in  forming  clubs. 

Dr.  Barron  suffered  much  mental  anxiety  in  the  year 
188G,  and  in  the  autumn  of  thitt  year  the  fir:^t  symptoms 
of  diabctoa  made  their  appearance.  He  never  deceived 
himself  aa  to  the  result,  but  preferred  to  work  on  until 
the  end,  rather  than  give  up.  Ah  a  matter  of  fact  he 
visited  patients  two  days  before  his  death,  and  the  tinnl 
end  wa3  due  to  his  catching  cold  on  his  rounds. 

Richard  IJroughton  Bothamley,  M.R.C.S.Eng.,  L.S.A.., 
died  oD  Mareh  14th,  at  the  age  of  thirty-ei^ht.  Ho  was 
born  in  Liucoluahiro,  and  received  bis  medical  edueatiuu 
at  St.  Thomas's  Hospital.  At  Hir  William  Mac  Coi-mac's 
advice  in  lb7(>  he  went  out  to  the  hospital  of  the  National 
Society  at  Nish  during  the  Basso-Turkish  war,  and  did 
nervioe  also  in  the  field  in  that  war.  His  servicea  as  a 
surgeon  were  highly  appreciated,  and  he  was  decorated 
by  the  Ottoman  Government  with  the  Order  of  the 
Medjidi€. 

Soon  after  hia  return  to  England  he  engaged  in  prac- 
tice at  Bromley,  Kent,  where  he  was  highly  esteemed 
as  a  practitioner  by  all  ela.tscs,  and  heUl  the  ofhce^  of  Dis- 
trict Medical  Officer,  and  elan  that  of  Medical  Otiicer  of 
Health.  Ho  died  of  typhoid  fever,  and  umy  bo  said  to 
liave  fallen  a  victim  to  his  zeal  for  hi»  profession,  for  he 
worked  almost  to  the  last,  aud  kept  his  lied  but  tittle  over 


bat  bis  death  was  not  notified  otitil  after  tbc  last  anDual 
meeting.  He  waa  bom  at  the  Bridge  House,  Cromford, 
Derbrabire,  being  the  third  son  of  Abraham  Wheatcroffc. 
He  WAS  edncated  at  Unirersity  College  Hospital  aiid 
Sheffield  Medical  School.  He  was  elected  a  Kellowof  the 
Society  in  1870.  For  the  Inst  three  years  of  his  life  be 
practised 8t  Brandsburton,  in  the  East  Kidiuguf  Yorkshire, 
He  waa  devoted  to  his  patienie,  by  whom  ho  was  much 
beloved  and  renpected,  especially  by  the  poorer  class. 
He  was  also  a  .spurt^man,  and  was  fond  of  fishing.  He 
died  of  rhenmatic  fever  after  three  weeks'  illness. 

George  Charles  Kemot,  Ph.D.Giessen,  L.D.S.,  R.C.S., 
L.8.A.,  died  in  June,  1888^  at  the  age  of  sisty-fonr,  but 
his  death  alao  was  not  notified  until  the  present  year. 
Ue  practised  in  £lphinst«ne  Road,  Hastings,  and  waa 
elected  a  Fellow  of  the  Society  in  18iJ5.  He  was  the 
nnthur  of  works,  "  Ou  Afithma,  luflneiita,  and  Bronchitis," 
published  in  1852,  and  "  The  Qnestion  of  Vaccination,  its 
Advantages  and  Present  Dangers,"  published  in  1870. 

Dr.  OBCar  Previt  died  at  San  liemo  ou  March  19th,  at 
the  ago  of  ^fty-two.  He  was  bom  at  Riga,  where  his 
father  practised  iiti  a  medical  man.  He  was  edncated  at 
a  school  at  Birkenruli,  near  Wenden.  In  the  year  1857 
ho  proceeded  to  Dorpat  University,  He  there  studied 
medicine  from  1857  to  1861,  and  again,  after  a  short  in> 
terval,  from  18G3  to  1861,  taking  his  Doctor's  degi-eo  in 
1861.  After  thiii  ho  %isited  the  Universities  of  Berlin, 
Vienna,  Wurzburg,  ond  Paris.  On  his  return  from  abroad 
he  settled  in  practice  at  St.  Petersburg,  where  ho  held 
the  office  of  Director  ("  Ordiuator ")  of  an  ophthtilmic 
hospital  from  Soptembei",  1865,  to  March,  1867.  Ho  then 
removod  to  Jaroslaw,  being  nppoinled  Director  of  the 
State  Hospital  in  that  town.  Next  he  was  appointed  chief 
physiciao  to  the  Gyuaicological  Department  of  the  Fin- 
delhans  Lying-in  HoHpiLal  at  Moscow,  nnd  passed  the  last 
years  of  bis  life  in  that  city,  where  ho  had  a  large  obstet- 
rical and  gyuGDoological  practice.  Ue  waa  elected  a  Corro- 
apottding-  Fellow  of  our  Society  in  1876. 


I 


XmSVi-L  AOUKKSS. 


Johr.  Rutherford  KipkpaLriclt,  M.D.Dubl.,  F.K.Q.C.P. 
Ircl&utl,  died  ou  April  I6th,  at  the  age  of  Mty-seveu. 
Ho  became  a  Licentiate  of  the  Royal  College  of  Sur^ous 
of  Irelaad  iu  1855,  and  two  years  aubsetiueutly  obtained 
the  Folluwr'ship  of  that  Cullogei  Lj*  examination,  but  in 
1879  resigned  it  on  being  elected  a  Fellow  of  t]i«  Itoyal 
College  of  Pbyincians  of  Ireland,  of  which  be  had  pi-e* 
vioualj  been  a  Licentiate.  Ho  was  also  an  M.B.  of  the 
UEiveraity  of  Dublin,,  having  been  educated  at  Trinity 
Collo^,  Dabhn,  nnd  took  the  M,D.  degree  in  18S:J.  He 
was  appointed  AsRislunt  to  the  late  Dr.  McClintockj  the 
then  Master  of  tho  Rotunda  Hospital,  about  the  year  1858j 
and  served  in  that  capacity  for  the  usual  term  of  three 
years.  In  1882  ho  was  elected  King's  Professor  of  Mid- 
wifery by  the  Fellows  of  the  Royal  College  of  Physicians, 
and  lectnred  in  the  school  of  the  University  of  Dublin. 
His  seven  years'  term  of  office  would  have  expired  in  July, 
and  very  recently  he  was  re-elected  for  a  ftirtlier  term 
of  sewn  yeai-s.  He  was  also  Obstetric  Physician  to 
Sir  Patrick  Dun's  Hospital,  and  Physician  to  the  Maternity 
Charity  iu  connection  with  it.  U«  waa  a  Member  of  the 
Boyal  Society  of  Dublin,  and  a  Fellow  of  the  Academy  of 
Medicine  in  Ireland,  and  hud  been  Kxatuiner  in  Midwifery 
for  the  College  of  Surgeons  and  the  Queen's  University  of 
Irelaud.      He  was  elected  a  Fellow  o!  this  Society  in  18(32. 

Dr.  KIrkpalrick'a  life  was  coinpnrutivfly  uneventful. 
He  did  not  contribute  very  largely  to  lilerature,  but  was 
the  author  of  various  papers  on  obstetrical  subjects,  among 
which  may  be  mentioned  one  "  On  the  Prevention  of 
Accidents  arisiag  from  the  Use  of  Pessariea,"  and  onu  un 
the  "  MauikgemeiLt  of  the  PerinEeum  during  Delivery." 
Ho  soon  acquired  a  very  large  obstetric  practice,  which 
ho  retained  np  to  tho  date  of  his  lost  illness.  Uia  kind 
and  gentle  maimora  endeai-cd  him  to  his  patients.  He 
was  beloved  and  esteemed  by  all  who  knew  him,  and 
never  bad  nn  enemy.  Hix  health  had  been  for  some  timo 
declining.  The  aclaal  cause  of  death  was  not  ascertained, 
but  he  became  very  aneemic,  and  appeared   to   die  of 


94 


AKMFAI.  ADD  BBSS. 


anEemia.  His  t-emams  were  interred  in  Mount  Jeromo 
OomatSFyj  and  the  funeral  was  large  and  represeutntive. 

Lawrenco  Treat  Cnmberbatcli,  M.D.  St.  Andrews, 
M.H.C.P.Loiid.,  M.R.C.S.Eug.,  died  August  IStli,  at  the 
age  i)E  sixty-five.  He  wns  born  at  Barbadoes,  where  his 
father  owned  an  eetatc.  Barlj  iiiclination  led  him  to  the 
study  of  medicine,  and  at  the  ago  of  sixteen  he  entered 
as  a  student  at  Trinity  Coltege,  Dublin,  where  he  took  the 
degree  of  B.A.  in  184(i.  After  tliis  he  studied  for  soma 
time  in  Paris,  and  thou,  in  184y,  took  the  Membership  of 
the  Royal  College  of  Surgeons  of  England,  not  bcjnff  nblo 
to  afford  the  time  uecosaary  to  graduate  in  medicine.  Ha 
nextbccume  assistaDt  to  a  practitioner  at  Chipping  Norton, 
who  Lad  an  extensive  practice,  and  held  several  appoint- 
ments, iiiduding  a  large;  Uuion.  By  laborious  work  iu 
this  position  be  gained  extensive  experience  both  in 
obstetrics  and  in  general  medicine  and  surgery. 

His  first  commencomout  of  practice  iu  Loudon  was 
decided  by  an  accident.  A  nomination  for  a  coramiasion 
IIS  assistant-Burgeoa  in  the  array  had  been  obtained  for 
him  ;  be  had  resigned  Lie  appoiutineut,  and  had  come  np 
to  London  to  present  himself  nt  the  War  Offioe.  It  was 
then  found  that  Lis  diploma  of  M.B.C.S.Kng.  could  not 
for  the  moment  bo  produced,  hia  ancle  to  whose  care  he 
had  entrusted  it  being  out  of  town,  and  thus  his  com- 
mission was  lost.  In  this  dilemma  he  decided  to  com- 
mence practice  near  Lowndes  Square  ;  and,  having  influ- 
ential relations  and  frieuds  at  the  West  End,  he  soon 
began  to  attain  success. 

Eventually  he  decided  to  give  np  general  practice,  and 
limit  himself  to  obstetric  and  medical  work  as  a  physiuiau. 
AccDi-diugly,  in  IS&O  be  took  the  degree  of  M.D.  at  St. 
Andrews,  and  the  Membership  of  the  Itoyal  College  of 
Physicians  of  London,  His  inclination  for  obstetric  prac- 
tice wfts  mnob  encouraged  by  three  inHuential  friends,  all 
having  largo  and  fashionable  midwifery  prjvctices,  the  bite 
Sip  Charles  Lococt,  Br.  Cape,  and  Dr.  Gream.  AH  these 
availed  themselves  frequently  of  Lis  obstetric  skill ;  and 


I 


AKHDAL   ADD  BESS. 


95 


thus  it  happened  that  beFore  long  Dr.  CumWrbatch  him- 
self was  in  the  full  tide  of  a  large  obstetric  practice  among 
the  upper  classes  at  the  West  End. 

His  great  success  was  the  more  remarkable  from  the 
iact  that  the  only  public  appuinttuent  he  ever  hohl  wns 
that  of  phynician  to  the  Economic  Lite  Insurance  Office, 
which  he  retained  up  to  the  time  of  liig  death.  It  was 
dne  to  his  own  talent,  iiidustiy,  and  professional  skill. 
A  writer  in  the  '  Laucel '  nays,  "  Only  those  who  have 
hod  the  advantage  oF  meeting  him  in  consultation  can 
know  bow  yahmblc  was  his  opinion  j  how  thoroughly 
honext  aad  straightforward  ho  was,  and  of  what  comfort 
and  support  in  difiicnlt  and  complicated  cases.  To  his 
patients  he  endeared  himeelf  by  his  sympathy,  aa  well  as 
by  his  HuccesH  in  treating  thi'm.  In  addition  to  being  n 
good  classical  scholar  he  was  well  read  in  subjects  apart 
from  his  profession,  and  was  always  thoroughly  versed  in 
the  topics  of  the  day.  As  a  host  or  at  a  dinner  party  he 
was  delightful,  and  those  wltu  have  met  him  know  what 
BD  aM^nisitinn  he  wa^i.  Full  of  amusing  anecdote  and 
sparkling  humour."  Dr.  Cuinberbatch  was  elected  a 
Fellow  of  our  Society  in  18C2,  was  a  Member  of  Council 
from  laetf  to  1870,  and  was  Vice-President  in  1878. 

Dr.  Curobcrbatch  had  had  a  warning  about  seven  years 
before,  discopcnng  that  his  pulae  had  suddenly  fallou  to 
■bout  4rO  in  the  uiuute.  Acting  on  tlii>  advice  of  medical 
friends  whom  he  consulted,  he  then  gave  up  his  midwifery 
prtctice,  and  limited  himself  to  consulting  and  medical 
work.  Nevertheless  he  remained  fully  occupied  with  the 
work  which  now  fell  to  his  Bhare  as  a  general  physician. 
After  a  busy  sessou  he  left  Loudon  on  the  uigbl  uf 
AagoiitlGth  to  join  his  cousiu'a  yucht  in  8cothind.  With 
tlte  exception  of  some  fatigue  ho  appeared  well  on  his 
urrival.  On  Sunday,  l8th,  at  breakfast,  he  appeared  in 
his  usual  spirits.  Soon  afterwards  he  was  seized  with 
sstero  pain,  which  at  first  he  attributed  to  indigestion,  but 
which  was  evidently  angina  pectoris.  He  remarked  that 
he  had  had  a  flight  attack  of  the  same  kind  the  previous 


fi6 


AKNDAL  ADSICKSS. 


Sunday.  The  p&in  iucreaaed,  and  in  less  tliaa  half  ao 
hour  from  the  moiaent  of  seizure  he  <lie<J. 

Francis  Jninee  Bailey,  L.R.C.P.Lond.,  M.B.C.S.Eug., 
iiud  L.S.A.,  died  October  ;^Oth,  at  the  age  of  fifty-six. 
He  was  the  sou  of  Mr.  J.  Bailey,  sui-geoa  of  Biackburu. 
He  ^ttidiod  luedieine  at  Chariug  Cross  Hot^pital,  took  thd 
quallEcations  of  M.E.C.S.lilag.  and  L.S.A.  iu  185(5,  and 
in  iy7!  becume  li  Licentiate  of  the  Hoyal  College  of  Phy- 
Dicians  of  London.  He  began  practice  in  Livei-pool  as 
partner  to  Dr.  Nottage,  and  took  the  practice  on  the  re- 
tirement of  the  latter. 

He  acquired  a  high-class  practice,  was  well  known  in 
professional  and  literary  circles,  and  took  an  actlvo  part 
in  the  wort  of  several  learned  societies.  He  was  Vico- 
Prtsidcut  o£  the  LaucAshire  and  Cheshire  Historic  Society 
for  upwards  of  eleven  years,  and  also  President  of  the 
Liverpool  Pliiloniatliic  Society.  At  the  time  of  hia  death 
he  was  Chairman  of  the  Dental  Hospital,  and  Vice-President 
ot"  the  Liverpool  Medical  Institution.  He  was  also  a  pit)- 
miaent  mason,  being  P.M.  of  the  Croxteth  United  Service 
Lodge.  He  was  much  interested  in  the  education  of  tho 
deaf  and  dumb,  having  served  for  seventeen  years  as 
Honorary  Surgeon  to  tho  Deaf  and  Dumb  School,  and 
also  to  the  Adult  Deaf  and  Dumb  Society.  At  the  last 
uoctiog  of  the  Medical  Institution  before  his  death  he 
spoko  against  tho  introduction  of  the  pure  oral  method  of 
traiuiug  the  deaf.  He  held  tho  rank  of  Surgeou-Mujor 
(Honorary  Lieutenant- Colonel)  in  the  volunteers,  having 
served  in  bis  corps  since  IQGZj  and  baTing  accompanied 
it  to  Aldershot  in  1886. 

Dr.  Bailey  had  not  been  in  good  health  for  some  time, 
but  continued  his  ordinary  work  till  the  day  before  his 
death.  Ho  had  an  apoplectic  seizure  of  a  very  severe 
character,  never  rallied,  and  died  in  a  fow  hoarn.  His 
funeral  was  attended  by  a  nuacrouE  citcle  of  frionds  from 
the  medical  profession,  tho  Volunteer  force,  and  Masonic 
body,  ns  well  as  from  tho  learned  uocietiea  to  which  he 
belonged. 


ItfiSS. 


«7 


Dr.  Bailey  irafl  elected  a  Fellow  of  our  Society  in  1880, 
and  contri1>ut6d  to  the  journats  some  papiers  od  o1>atetnc 
subjects. 

The  scienlilio  work  ot  our  Society  during  the  year,  as 
contained  in  tho  volume  of  *"  Transactions '  juKt  ready, 
will  be  found,  1  Taelieve,  not  to  fall  short  of  that  of  previous 
years.  The  spec!  mens  shown  hare  been  of  great  patbologncal 
interest,  bcariu^  mainly  upon  diseaees  of  women,  but  in 
some  coses  also  upou  points  conuecti'd  with  obstetrics. 

No  lees  than  four  specimens  bayi;  been  shown  of  aaeu- 
coplialic  fcetus,  and  we  haii'e  liad  besides  "Notes  ou  a 
Caae  of  Anencephalic  Monster"  in  the  form  of  a  paper  by 
Dr.  H.  C.  Hodges,  One  of  these  moustei-ii  shown  by  Mr. 
Alban  Doran  had  the  pecnliaritj  that  there  was  a  mass  of 
rudiineatary  brain-snbst&nce  covered  with  pia  niaterj  which 
Mr.  Doran  considered  to  snpport  the  theory  that  the  anence- 
phalic  monster  results  from  rupture  of  a  hydrocephalic 
head  at  the  third  or  fourth  week  of  pregnancy.  In  Mr. 
Hodges'  caso  there  wns  a  soft  pedunculated  brain-sac, 
lying  behind  the  frontal  bone,  which  was  ruptured  m  do- 
Uvery. 

We  hare  bad  also  an  unusual  number  of  specimens 
bearing  on  the  pathology  of  pelvic  hietnatocele.  While 
some  of  the  t^ourceaof  blcxid  which  are  commonly  assumed 
to  be  possible  in  this  affection,  such  as  regurgitation  from 
the  Qterus  of  nion»;trual  blood,  or  rupture  of  varicose  veins 
intbe  broad  ligament,  rest  rather  upou  n  ^rt'ori  assuiuptiou 
than  upon  demonstration,  it  has  been  abundantly  proved 
that  one  possible  cause  is  bleeding  from  a  diseased  Fullo- 
pian  tube,  whose  ostium  remibiuH  patulous.  Two  spoci- 
mens  where  this  condition  had  given  rise  to  hsematocele 
were  shown  during  the  year,  one  by  Dr,  Playfair,  one  by 
Dr.  CuUiugworth.  Another  aouiewhut  different  source  of 
liajmorrbage  woe  shown  in  another  specimen,  presented 
also  by  Dr,  CulUngworth,  in  which  a  hn)matos)ilpiux  had 
roeulLed  from  rupture  of  a  vurieose  vein  in  the  lining  of 
the  Fallopian  tube.  How  small  may  be  the  source  of  a 
fata!  intra-pelvio  hstnorrhage  was  strikingly  illustrated  by 
TOL.  XXXU.  7 


08 


ANN  DAL   AODBKSS, 


a  specimen  shown  by  Mr.  Knowsley  Thornton,  in  wHch  an 
extm-Qterine  &ao,  not  larger  than  a  hnzel-nut,  and  Bitiiatod 
closa  to  the  angle  of  the  uterus,  bud  ruptured,  Mr. 
Thornton  deduced  from  the  specimen  the  important  ang- 
gestiou  that  in  such  a.  c&se,  the  patient  being  greatly 
coUapa«d,  it  would  be  better  not  to  remove  the  tabe,  but 
Bimply  arrest  the  bleediug  by  a  double  ligature.  A  still 
more  rare  form  of  fatal  iatra-pelTic  haemorrliage  was  illus- 
tratod  by  a  specimea  of  pelvic  hiema,toma  after  delivery, 
presented  by  Dr.  Boxall. 

The  rarer  forms  of  tumonr  in  or  near  the  ovaries  have 
been  illustrated  by  several  specimens.  Two  were  o£  6bro- 
myxosarcoma  o£  the  ovary,  shown,  one  by  Dr.  Handfield- 
Jonesj  one  by  Mr.  Meredith.  Dr.  W.  Duncan  showed  a 
nayoma  of  the  broad  ligament ;  while  tumours  of  the  ovary, 
partly  adenomatous,  partly  dermoid,  were  shown  by  Mr. 
Bland  Sutton  and  Dr.  Carter. 

Many  apecimens  have  been  sliown  throwing  further 
light  upon  inflammatory  disoaeos  of  the  uterine  appendages. 
Distended  tubes  have  been  shown  by  Dr.  W.  Duncan,  Dr, 
J.  Phillips,  and  Dr.  Culliugworth.  But  the  specimett 
■hown  by  Dr.  Playfnir  was  of  special  practical  significance, 
where  death  hnd  followed  the  skilful  aud  successful  re- 
moval of  an  intpa-utorine  polypus,  and  was  found  to  be  due 
to  a  pyosalpinx  which  had  escaped  detection.  Still  mora 
instructive,  from  the  pathological  point  of  view,  were  the 
specimenB  associated  with  the  paper  on  the  "  Closure  of 
the  Ostium  in  Inflammation  and  Allied  Diseases  of  the 
Fallopian  Tube,"  by  Mr.  Albau  Dorau,  who  based  upon 
theae  specimens  a  distinction  between  salpingitlc  cloeure 
and  perimetritic  closure  of  the  ostium. 

A  curious  point  bearing  upon  the  microscopic  diagnoflial 
of  the  nature  of  membranes  expelled  from  the  utems  wu 
raised  by  a  specimen  of  dysmenorrKoeal  membrane  ex- 
hibited by  Mr.  Alban  Dorau.  The  patient  had  had  her 
ovaries  and  tubes  removed  n  year  before,  and  sections  of 
the  membrane  showed  large  cells  resembling  decidual 
celtfl, 


ABVC^AI.   ADDRESS. 


99 


special  interest  attacL^e  to  Dr.  Miinchmeyer's  apparatus 
for  the  trausfusiou  into  tha  cellalar  tiasue  of  a  sfreriliaed 
Kaline  eolutiun  in  cnees  of  heQmorrbii.ge,  which  was  abown 
by  Dr.  KTattliews  Duncan.  The  interest  belongs  not 
merely  to  the  actual  instrument,  but  to  the  faot  that  any. 
one  can  easily  improvise  an  apparatus  for  carrying  out 
this  method,  which  ha»  been  practised  to  a  considerable 
extent  in  Germany  and  elsewhere,  and  which  la  alleged  to 
give  rctiult«i  quite  us  great  as  tlioae  of  an  intra-veDoua  in- 
joctiOQ  of  saline  fiuid.  All  that  is  wanted  is  an  aspirator 
needle,  Bterilised  by  the  flame  of  a  spirit  lamp,  a  piece  of 
elastic  tubing,  and  a  large  funueE.  Ad  antieeptie  Bolution 
is  first  passed  through  the  apparatas,  and  then  the  tialine 
aolation  is  injected  into  the  celtulur  tiHsiie  by  the  force  of 
gtvmiy.  It  is  diffused  in  that  tiesue,  if  necessary,  by 
maMage  ;  and  the  flow  can  be  accelerated  by  running  the 
oiled  finger  and  thumb  down  the  outside  of  the  tube. 

Yet  it  may  be  well  to  remember  the  investigatiuu  made 
some  years  ago  by  Prof.  Schafer  for  titis  Society  by  numo- 
roos  experiments  on  nnimnli?.  Prof.  Scbiifcr  coucludod 
from  those  exporirocnt*  that  the  cause  of  death  is  generally 
lack  of  snfficient  blood-corpuscles  to  carry  on  respiration, 
that  intra-venous  injectiouK  of  Baliue  fluid  are  therefore  of 
no  avail,  and  that  the  only  means  of  saving  life  is  direct 
tranafusion  of  blood  from  an  animal  of  the  same  species. 

The  papers  of  the  year  have  been  somewbat  above  the 
avemgc  in  number,  aod  midwifery  hiis  not  had  quite  so 
much  prcpondemnce  as  usual  over  the  diseaBes  of  women. 
Of  twcnty-ono  papers,  eleven  were  on  obstetric  subjects, 
nine  on  disenecs  of  women,  and  one,  by  Dr.  Hodges,  on 
biematemesis  in  a  new-born  infant. 

Dr.  J.  Phillips's  paper  on  "Acnte  Non-septic  Pnlmonary 
Disorders  ns  Complications  of  the  Puerperium  "  mised 
various  questions  of  great  interest.  The  author  adduced 
evidence  to  ^how  the  existence  of  a  disea8e  distinguishable 
by  its  fligns  fi-om  ordinary  pneumonia,  and  having  special 
relations  to  phlegmasia  dolens,  from  the  fact  that  it  oc- 
cmred  about  the  same  date  in  tho  pucrperiam,  and  that 


100 


ASNOJLL  ADDRESS. 


pTilegmasm  dolens  was  in  several  Cfises  a  complipation. 
ile  considered  that  it  arose  from  genenil  ihrombosis  of  tha 
minute  pulmonary  venules,  produced  hj  the  same  condi- 
tion of  tLoWood  wliicli  is  productive  of  phlegmasia  doleuii. 

Some  of  the  apeukers  were  doubtful  of  the  uou-utptio 
character  of  the  oasos,  and  porliapa  tho  difference  may 
really  lie  in  o«r  dofinition  of  septiciemia.  For  the-  saiiie 
doubt  occurs  about  phlegmasia  dulsuB  itself.  Some  regard 
it  as  septic,  while  others  refnuo  it  that  title,  on.  account  of 
ita  late  occnrrenoe  and  its  favourable  prognosis.  If  this 
Bpecial  pneumonia  depends  upon  a  form  of  microbe  differ- 
eufc  from  the  ordinary  microbe  of  pneuraonin,  and  from 
those  of  any  named  aymotic  diseaseSj  and  if  the  puerperal 
state  16  a  necessary  predisposing  cause,  ought  wo  or  ought 
mre  nut  to  refuse  to  include  it  in  aepticoimia,  because  the 
microbe  probably  doos  not  gain  accosa  through  the  genital 
canal?  I  think  wo  can  scarcely  do  80  logically  if  we  give  the 
word  septicajmia  its  widest  uieaning.  For  1  am  not  my- 
self prepared  to  agree  with  one  of  tha  Bpeaker.-^  thdt  ecpti- 
ca3mia  is  a  disease  with  a  course  and  phonomeua  &b  defi- 
nite as  tliose  of  any  other  infectious  disorder.  Rather,  it 
varies  in  degree  froui  an  evanescent  febrile  diiitiirbanco 
to  the  most  virulent  and  fatal  disease  ;  aud^  as  to  its  pheno- 
mena, there  are  the  greatest  varieties  as  to  the  presence 
or  absence  of  peritonitis,  parametritis,  phlebitis,  lympban* 
^tis,  and  other  local  lesions.  And,  though  we  do  not  yet 
know  enough  of  its  bacteriology  to  esplaiu  it,  tho  microbes 
which  liavo  been  found  are  not  of  ono  apocios,  but  of 
several. 

Dr.  Handfield-Jonoa' paper  on  "  Chorea  in  Pregnancy" 
contained  the  reports  of  two  cases  marked  by  the  associa- 
tion of  chorea  with  mauiaeal  disturbance.  The  author 
regarded  chorea  in  pregnancy  as  an  example  of  disordered 
function ;  other  speakers  considered  that  the  term  func- 
tional disorder  is  in  thifi  case  only  an  expression  of  onr 
ignorance.  Neither  this  nor  any  other  paper  has  yet  fully 
cleared  up  the  mystery  of  chorea,  especially  as  regards 
tlie  relation  between  psycKic  causes  and  organic  lesioDs. 


AmtFAL  ADDBIBS. 


101 


In  ono  ease  chorea  reanlted  from  fright  at  theClerkcnwol! 
esploBion.  Tho  patient  died,  Btid  at  the  nocropsy  wore 
seen  those  vegetations  on  the  cnrdmc  vulvos  wliiuh  are  so 
generally  found,  even  when  there  baa  been  no  bruit  dur- 
ing life.  How  can  a  fright  produce  vegetations  on  tbe 
valves?  or  wK&t  intermediate  Uuka  of  causation  can  be 
imagined  between  theio,  eapeciaily  when  wo  remember 
that,  according  to  ojie  theory,  tlie  vegetations  are  the 
primary  canse  of  the  chorea  ?  Similar  considerations 
apply  to  the  relation  of  chorea  to  pregnaacy. 

In  his  paper  on  "  Ctesarean  Section  for  ContraoteJ 
Pelvis,"  Dr.  Cliampneys  gave  a,  very  full  report  of  a  suc- 
cessful oporatioQ  carried  out  according  to  Stinger's  method. 
In  this  operation  tlie  novelty  was  introduced  of  steriHaing 
the  patient,  not  by  removing  the  ovaries,  hut  by  tying  tho 
tubes  with  kangaroo  tendon. 

Dr.  Herman  contributed  three  valuable  papers,  the  re- 
snlt  of  extensive  clinical  observations  :  "  A  Contribution  to 
the  Anatomy  of  tho  Pelvic  Floor,"  "  The  Changes  in  the 
Pelvic  Floor  which  accompany  Slighter  Degrees  of  Pro- 
lapse," and  u  paper  on  "  Five  Cases  o£  Puerperal  Kclanip- 
atfti"  In  tho  last  it  was  shown  that  cases  of  eclampeia 
differ  materially  from  each  other;  but  the  most  constant 
feature  appeared  to  bo  the  diminution  of  the  excretion  of 
nreiL,  though  not  invariably  of  the  qiiaulity  of  urine,  dur- 
ing the  period  of  the  fits. 

Two  cases  of  reposition  of  an  inverted  uterus  were  re- 
oorded,  one  by  Dr.  Braxton  Hicks,  on©  by  Dr.  Newman. 
Other  papers  on  obstetric  subjects  were  on'"  Diagnosisof 
Placenta  Prifvia  by  Palpatiou,"  by  Dr.  Spencer  ;  "  Lacera- 
tion of  Vagina  in  Labour,"  by  Dr.  Matthews  Duncan  ; 
and  "  Shall  Pregnancy  be  terminated  prematurely  in  Cases 
of  Phthisis?  "  by  Dr.  W.  Duncan.  On  gyniecological  sub- 
jects we  have  bad  papers  on  "  Chlorosis  and  Menstrua- 
tion," by  Dr.  Stephynson  ;  "  Large  Chylous  Cyst  of  the 
Mesentery,"  by  Dr.  Itasch  ;  "Vesico-utero-vaginalFlBtula," 
by  Dr.  Cullingworth  ;  and  "  Lnpiis  of  the  Vnlvn,"  by  Dr. 
liBwers. 


102 


AHHOAL  ADDEESB. 


TLere  are  other  subjects  attracting  special  interest  at 
the  present  tirae,  eapeciallj  ou  the  Continent,  on  which 
we  have  not  had  papers  during  the  past  year,  but  may 
hope  for  further  commnni cation 3  in  future.  One  of  these 
is  the  operative  treatment  of  ciineer  ot  the  cei'vix  uteri. 
It  is  generally  assucuod  tliat  the  spread  of  the  disease  is 
more  outward  than  upward;  and,  in  -view  of  this  fact, 
when  the  suhject  was  last  discnssed  in  our  Society  the 
general  opinion  was  in  faTour  of  the  supra-raginal  ampu- 
tation rather  tha,n  total  extirpation  of  the  uterus  through 
the  vagina.  Bnb  thia  decision  must  be  cither  confirmed 
or  modified  in  view  of  more  recent  experieoce.  It  is 
known  that,  in  some  exceptional  casem,  extension  upward 
to  the  body  of  the  uterua  is  oven  more  rapid  than  exton- 
aion  outwards,  and  it  would  be  of  importance  to  hnowthe 
relativo  frequency  of  tliese.  In  Germany  opinion  inclines 
rather  toward  total  extirpation  ;  and  Dresden,  which  baa 
obtained  cuch  wonderful  results  in  Ciesarean  section,  claims 
a  mortality  of  only  '»  per  cent,  after  totivl  vaginal  extir- 
pation, and  a  percentage  of  more  than  25  free  from  re- 
cnrrence  after  two  years.  On  the  other  hand,  it  ia  con- 
tended by  BOme  that  recurrence  ia  bo  general  after  supra- 
Taginal  amputation,  and  the  pains  of  deep-seated  recur- 
rence so  much  greater  than  that  of  the  untreated  disease, 
that  it  is  better  to  abstain  from  all  attempts  at  extirpation. 
It  would  be  of  importance  also  to  confirm  or  correct  the 
observations  of  some  German  authorities  who  find  the 
endometrium  of  the  fundus,  even  when  not  reached  by  con- 
tinuous extension  from  the  cervix,  yet  almost  invariably 
diseased,  either  by  actual  sarcoma  or  by  n  proliferating 
endometritis  suggestive  of  commencing  inaligimncy. 

Another  eubject  is  the  treatment  of  complete  rupture 
of  the  aterus  in  labour.  This  was  indeed  raised  during 
the  past  year  by  a  specimen  shown  by  Dr.  Horrocks,  and 
the  opinion  was  oxpreaaed  that  abdominal  section  ought 
always  to  be  performed,  and  the  uterus  removed  by  Porro'e  1 
method,  if  the  rent  could  not  be  Bewn  up.  But  removal 
of  thent«rus  muBt  add  to  the  great  shock  already  exititing; 


VOTSa  O?  THASKB. 


108 


and,  tlie  rent  being  in  the  lower  distensible  segment,  and 
often  spreading  into  tiie  broad  ligament,  it  cau  rarely  be 
possible  completely  to  remove  tlie  torn  portion,  In  con- 
nection wicli  tliis  siiTjject  tlie  auccefisful  boldness  of  Leopold, 
who  left  iodoform  gauze  for  a  time  in  the  peritoneal  cayity, 
to  secure  apposition  through  pressure  of  the  peritoneal 
edges  which  could  not  be  sewn,  is  deserving  of  attention. 
Gentlemen,  I  thank  }'0a  heartily  for  the  courtesy  which 
you  have  shown  me  since  I  have  occupied  this  chair,  and 
I  look  forward  with  a  confident  hope  to  a  year  of  yet  more 
valuable  work  in  our  new  meeting-room. 


Dr.  GiiBTia,  in  proposing  a  resolution  of  thanks  to  the 
President  for  his  address,  said  it  was  worthy  alike  of  his 
genius,  hia  reputation,  and  his  position  as  FreHident  of  so 
important  a  Society  ;  and,  beyond  the  thanks  that  were  due 
for  the  address,  the  Society  was  alao  deeply  indebted  to  the 
President  for  the  care  which  ho  had  taken  of  its  intereets 
in  the  negotiations  with  the  Royal  Medical  Bud  Chirurgioal 
Society,  and  for  tho  very  H-ble  manner  in  which  he  had 
brought  them  to  a  pleasant  and  satisfactory  conclusion. 

It  was  then  moved  by  Dr.  Qkevis,  seconded  by  Dr.  John 
Williams,  and  carried  with  enthusiasm — "That  the  best 
thanks  of  the  Society  bo  given  to  Dr.  Galabin  for  his 
interesting  address,  and  that  he  be  a&ked  to  allow  it  to 
be  printed  in  the  next  volume  of  the  '  Trauaactions.'  " 

A  vote  of  thanks  to  the  retiring  Honorary  Secretary 
(Dr.  Percy  Boultou)  and  the  retiring  Honorary  Librarian 
(Dr.  HorrocJcs)  was  moved  by  Dr.  Heeman,  seconded  by 
Dr.  AcBT  Lawkksce,  and  carried  unanimouely.  In  speak- 
ing on  this  vote  Dr.  Williams  referred  to  the  heavy 
extra,  duties  which  had  been  undertaken  by  Dr.  Boulton 
in  consequence  of  the  negotiations  with  the  Royal  Medical 
and  Ghirurgical  Suciety^aud  most  ably  coudocted  by  that 
gentleman. 

A  vote  of  thanks  to  the  retiring  Vice-Presidents,  Dr. 
Brodie,  Dr.  Cleveland,  Dr.  George  lioper,  and  Dr.  William 
Stophonsou,  and  to  the  other  retiring  Members  o£  Council, 


104 


VOTBB  OF  THiNKS. 


Br.  W.  Duncan,  Pr.  Handfi old- Jones,  Dr.  Hurry,  Dr. 
Lewors,  Mr,  Lowe,  and  Dr.  John  Phillips,  was  luoved  by  Dr. 
Lkith  Napibr.  He  said  that  however  esoelleut  the  Pre- 
sident for  tbQ  time  might  be,  it  iriis  essential  that  lie  should 
be  wisely  aud  efficiently  supported  by  his  officers  and 
ooimcillors.  The  work  o(  the  Vice-Presidents  might  not 
l)e  onerous,  but  their  positions  were  honourahle.  Witt 
regard  to  the  four  retiring  Vice-PrLieidonte,  Dr.  Napier 
felt  auro  that  he  expreseed  the  convictions  oE  all  present 
in  saying-  that  four  more  thoroughly  worthy  and  highly 
apprcfiiited  gentlemen  had  never  served  the  Society.  One 
oi  those  gentlemen  h&A  now  ceased  practising  Ins  profes- 
sion, after  hnving  well  earned  his  honorable  leisure.  Of 
him  Dr.  Napier  might  stiy  that  no  more  entliUHinstic  or 
devoted  Pellow  ever  helonged  to  the  tSociety.  For  years, 
in  the  midst  of  a  busy  life,  he  had  found  it  a  haven  of  rest, 
and  lie  rightly  valued  highly  the  horiouiuble  place  which 
he  oocapied.  The  other  three  gentlemen  were  still  with 
thorn  professionally,  aod  Dr.  Napier  trnsted  to  seeing  thoin 
OOOUpy  a  yet  hlglicr  puaitiuu  in  the  Suciety  than  that  they 
had  just  quitted.  The  duties  of  the  Council  had,  daring  the 
past  ycar^  been  peculiarly  arduous  and  trying.  It  argued 
well  for  tho  ftitnre  o£  the  Society  that  under  «11  circuui- 
Etanees  the  most  perfect  harmony  always  existed  between 
the  Council  and  the  general  body  of  Fellows,  While  the 
Council  lost,  the  Library  gained,  the  valued  aervlceB  of  Dr. 
Wm.  Dnncan.  Dr.  Napier  concluded  by  expressing  in  warm 
tertns  tlie  feeling  of  the  Society  thai  the  resolution,  al- 
though essentially  and  necesearily  formal,  waa  amply 
merited  by  the  gentlemen  to  whom  he  had  referred. 

Dr.  KoQTH  had  much  pleasure  in  seconding  the  motion 
of  Dr.  Napier.  Ho  would  not,  however,  make  an  eloc|uent 
onttioa  like  that  member,  but  he  would  say  that  every  one 
of  these  gentlemen,  whether  Vice-Presidents  or  otherwise 
Members  of  the  Council,  were  men  well  known  in  their 
profession.  He  therefore  felt  they  had  worthily  merited 
a  vote  of  thanks  for  excellout  work  done  iti  the  Society. 

The  votQ  of  thaukti  was  then  carried  unanimously. 


SPECIAL  GENERAL  MEETING. 

Maech  5th,  1890, 

A.  L.  Gaubin,  M.D.,  President,  in  tho  Ohair. 

Preaenfc— 40  Pellowa  and  I  Visitor. 

Books  were  presented  by  Mr.  AJban  Doran,  Dr. 
MatthewB  Duncan,  Dp.  Goodell,  the  Boyal  Medica.1  and 
Chimrgical  Society,  tlio  Ainorican  Oyii ecological  Society, 
the  St.  Bartholomew's  HoBpital  Staff,  and  the  "Westminster 
Hospital  Staff. 

J.  Fredk.  W.  Silk,  M.D.Lond. ;  Charles  Herbert  Tbomp. 
son,  B.A.,  M.D.Dubl. ;  and  C.  Percival  White,  M.lt.C.S., 
■were  admitted  FoIIowb  of  the  Society. 

Harry  St.  Clair  Gray,  M.D.  (Glaagow)  was  declared 
admitted. 

The  following  gentlemen  wore  elected  Fellows  of  the 
Society  : — William  John  Gow,  M.D.Lond.  j  and  A.  Aylmer 
Orr,  M.A.,  M.B.Oion. 

The  following  gentlemen  were  proposed  for  election  : — 
Aogustns  W.  Addinaell,  M.B.,  C.M.Etlin. ;  George  Edward 
Ansou,M.A.,  M.D.Oantab. ;  George  Black,  M.B.,  B.S.Lond.; 
Albert  Ebrinann,  L.B.C.P.LoDd.(Soutliara)i  Charles  Arthur 
Morria,  M.A.,  M.B.,  B.O.Cantab.,  F.B.C.S.;  Frank  Fredk. 
Scfaacbt,  B.A.,  M.B.Cantab.;  Hugh  Smith, M.D.Lond. ;  and 
Ernest  Allred  Snape,  L.B.C.I'.Loud. 

TOL.  xxiu.  8 


108 


ALTBEATION   Of  LAWS. 


The  following  additioniLl  Boction  to  Chapter  XIX  of  the 
Laws  was  put  to  the  meetiug  by  the  President  from  the 
Chair,  and  carried  uaanimoosly  : 

"  Chapter  XIX. — O?  the  Socibti's  Peopertt. — Seo.  2. 
—In  order  that  the  Society  may  in  all  respects  conform 
with  the  provisions  of  the  Statute  6  and  7  Vie-,  chap.  36j 
seo.  1,  the  Funds  of  tho  Society  shall  at  all  times  ba  de- 
voted to  the  purposes  for  which  it  was  instituted,  and  no 
Dividend,  Gift,  Division,  or  Bonus  in  Money,  shall  at  any 
time  be  mode  unto  or  between  any  of  the  Fellows." 

It  was  then  put  by  the  Presideot  and  carried  rtem.  con. 
that  Chapter  yill.  Sec.  1,  of  the  Laws  be  altered  bo  aa  to 
read  as  foUowe : 

"  Chaptkb  Vin. — Of  thk:  Tbustbbs. — 1.  There  shall  be 
three  Trustees  of  the  Society,  in  whom  all  the  Stocks, 
Funds,  and  SecuritieB  of  the  Society  for  the  time  being, 
Bnd  also  any  Freehold,  Copyhold,  or  Leasehold  property 
of  the  Society  shall  be  T«Hti-d  upon  trust,  from  time  to  time, 
to  pa.y  the  Dividends,  Interest,  Rents,  and  Income  thereof 
to  the  Treaauror  of  the  Society  for  tho  time  being,  and  to 
apply  and  dispose  of  attch  Stocks,  Funds,  Securitios,  Pro- 
perty, and  Income  for  the  benefit  of  the  Society  in  such 
manner  as  shall  be  directed  by  the  Council,  subject  to  tho 
control  of  General  Meetings  of  the  Society  ;  and  upon  going 
out  of  office,  the  Trus^tees  shall  execute  all  necessary  deeds 
and  instrunjenta  as  the  Conncil  shall  require,  for  vesting 
all  their  iutereab  in  the  funds  and  property  of  the  Society 
in  their  eucceaaors  in  the  Trust." 


The  Meeting  then  confirmed  the  action  of  the  Conncil 
with  regard  to  the  terms  of  the  Lease. 


107 


Beport  on  Dr.  Robmson's  Specimen  of  Placenta  PrsBvia 

(p.  67). 

The  ntems  has  been  opened  along  its  front  wall,  to 
which  the  placenta  was  attached.  The  placenta  is  com- 
pletely detached,  bat  it  is  impossible  to  say  how  much  of 
this  detachment  is  due  to  its  dissection.  The  insertion  of 
the  placenta  was  probably  marginal,  but  the  condition  of 
the  specimen  precludes  any  detailed  report. 

W.  S.  Platfaib. 

F.  H.  Chaufnxtb. 

C.  J.  GnLUNQWOBTH. 


108 


THB  BrpBcr  or  vni  bimdkb 


THE  CHANGE  IN  SIZE  OF  THE  CHEST  AND 
ABDOMEN  DURING  THE  LTING-IN  PERIOD, 
AND  THE  EFFECT  OF  TEE  BINDER  UPON 
THEM. 

By  G.  Eehbst  Hebman,  M.B.Lond.,  F.R.C.P., 

OaeTZCUIC  TSTSICIAM  TO  tB>  UfSVQV  HOaPITUi, 

(Beceived  November  Ttti,  1669.) 

{Ahsiraet.) 

Thb  author  says  tbu.t  tbore  axe  tliree  reasons  commonly  gireo, 
by  medical  men  or  bj  the  public,  for  the  uee  of  the  "  binder  " 
duiiDgtheIying-iiip«riod,  (1)  That  it  gives  eomfort.  (2)  That 
it  couuLeracts  the  iujurious  effect  of  tbo  euddeu  lowering  of  the 
intra-tibdoniina-l  pressure  consequent  on  the  eyacuation  of  tlia 
uterus.  The  author  points  out  that  It  is  not  usually  applied 
till  after  the  time  at  -which  ihn  lowering  of  preaaure  takus  place. 
(3)  That  it  keeps  the  waist  measurement  small,  and  so  preserrea 
the  "  figure  "  of  the  patient.  To  judge  of  this  it  is  necussarj 
to  liiiow  what  changes  normiilly  take  place  iu  the  tyiug-in 
poriod.  He  adduues  meaauretnunta  madeat  the  Ocaeral  Lying- 
in  Hospital,  which  show  that  during  the  first  ten  djijs  of  the 
Ijring'in  the  circumfcrenee  of  the  lower  )>art  of  the  ohest  (at 
the  level  of  the  ensiform  cartilage,  and  also  midway  between 
this  point  and  the  umbilicus)  diminish  b^*  rather  more  than  an 
inch.  This  diminution  ia  priicticallj  the  same  in  primipano  and 
tuultiparee,  and  is  not  modified  by  age.  Th«  effect  of  tbo 
"binder"  is  ascertained  by  comparing  different  (jlassea  of 
p&tieuts:  (1)  with  a  binder  as  ordinarily  applied  ;  (2)  without 
a  binder;  (3)  with  a  binder  to  the  continued  ti^'Ltnesa  of  which 
8p«cia)  attention  w&b  given.  It  w-ao  found  that  the  dimiuutiou 
in  size  of  the  lower  part  of  the  cheat  ia  practically  the  saow  in 
each  class.  The  author  therefore  concludes  that  the  ordinary 
binder  has  no  effect  uu  the  waist  measurement  of  the  jMtieut ; 


DUKlira   TEE   LTDfO-IH    PEBtOD. 


100 


althoagh  ho  does  not  doubt  that  by  the  use  of  an  unyielding 
bandage,  tigibt«iied  by  stripe,  defonuity  of  the  cheat  mig^bt  be 
produced  and  mainta,med.  The  sole  utility  of  the  ordiuarr 
bmder  is  aa  a  m«aa8  of  comfurt  to  the  patient. 

It  is  usual  aft^r  delivery  to  pat  a  "  biader  "  round  the 
ftbdomen.  There  are  several  reaaons  commonly  accepted 
for  this  practice.  One  that  may  be  given  is  that  the 
binder  afforda  the  patient  a  comfortable  sense  of  warmth 
and  support.  This  reason  is  good,  but  does  not  admit  of 
discussionj  because  the  sole  and  unanswerable  evidence  of 
this  effect  is  the  patient's  ipse  dixit. 

Another  reason  is  that,  unless  sonio  compression  be  ap- 
plied, the  sudden  lowering  of  the  intra-abdominal  pressure 
which  results  from  the  emptying  of  the  uterus  may  pro- 
dace  fiome  injurious  effect.  1  will  not  considorT?hat  these 
effects  may  be^  or  what  evidence  there  is  of  the  connec- 
tion of  such  effects  with  fheir  supposed  cause,  but  will 
only  point  oat  that  as  tho  binder  is  not  usually  applied 
uuttl  an  hour  or  so  after  the  sudden  diminution  of  pres- 
sure has  taken  place,  it  comes  too  late  to  prevent  these 
effects — at  least  such  effects  as  depend  upon  the  sudden- 
ness of  the  lowering  of  pressure, 

A  third  reason,  which  I  think  is  the  chief  one  in  the 
mind  of  tLe  public,  and  often  given  by  medical  men  to 
their  patients,  is  that  by  firm  binding-up  after  delivery, 
the  patient's  "  figare "  is  preserved.  Converselyj  we 
Bomctimcs  hear  the  blame  for  a  patieut's  portliness  being 
put  upon  the  medical  man's  want  of  attention  to  tht;  binder. 

The  alterations  in  the  figure  which  follow  repeated 
child-bearing,  are  difficult  to  distinguish  from  those  which 
are  merely  the  result  of  age  :  and  some  of  them,  each  as 
the  deposition  of  fat,  and  increased  curvabate  of  (he  spice, 
cannot  be  iu  the  least  affected  by  the  biader.  The  change 
irbioh  the  binder  is  presumed  to  modify,  is  the  enlarge- 
ment of  the  chest  and  abdomen.  That  the  girth  of  the 
waiat  can  be  reduced  by  comprespion,  is  shown  clearly 
enough  by  post-mortem  exatninatioos  of  patients  accus> 


no 


THR   BPFBCT   OF  TBB    BI¥DER 


tomed  to  lace  tightly.  I  therefore  aee  little  reaaon  to  doubt 
that  the  waist  can  be  redaced  during  the  Ijing-in  period 
as  well  as  at  other  times.  But  it  does  not  follow  that  any 
permanent  or  considerable  alteration  can  be  produced  by 
the  ordinary  binder  applied  during  the  week  or  fortnight 
following  delivery. 

Tiii&  communication  is  based  npon  measurements  made 
to  ascertain  what  change  takes  place  in  the  base. of  the 
chest  and  the  abdomen  during  the  lying-in  period,  and 
what  is  the  effect  of  the  ordinary  binder  on  these  oh&ngea- 
The  measurements  have  been  made  for  me  by  Dr.  C.  Owen 
Fowler  and  Mr.  G.  A.  Pratt,  house  physicians  to  the 
General  Lying'In  Hospital;  and  I  am  additionally  indebted 
to  Mr.  Pratt  for  help  in  calculating  the  averages  which 
are  snbinitted. 

The  only  observations  of  a  similar  kind  are  those  of 
Kehrer.* 

He  finds  the  average  circumference  of  the  base  of  the 
chest  in  twenty  virgins,  aged  from  20  to  30,  to  be  72'8 
cm. ;  in  twenty-one  primigravidra,  81*7  cm. ;  in  twenty-one 
meaeured  on  the  third  day  of  lying-in,  73'9  cm.  In  four- 
teen  seonndi gravid aa  the  average  circumference  was  80*9 
cm. ;  on  the  third  day  of  lying-in,  734  cm.  In  ten  multi* 
gravidee  the  average  circumference  was  81 '4  cm. ;  on  the 
third  day  of  lying-in,  75-7  cm.  The  total  of  the  whole  gives 
the  average  of  forty-five  gravidic  81"3  cm.;  on  the  third 
day  after  delivery,  74*1  cm. 

He  foand  the  greatest  circamference  of  the  abdomen  in 
113  first  pregnancies  to  be  96'6  cm.;  immediately  after 
delivery,  86-6  cm. ;  in  the  lying-in  period  {I  suppose  on 
the  third  day,  bat  this  is  not  expressly  stated),  82-C  cm. 
In  seventy-five  secundigravidae,  the  greatest  circumference 
was  99"3  cm;  immediately  after  delivery,  89*1  cm.;  in 
lying-in  period,  85'6  cm.  In  fifty  multigTuvidee  the  greatest 
circumference  was  1005  cm. ;  immediately  after  delivery, 
90  cm. ;  in  the  lying-in  period,  85*1  cm.     The  average  of 

■  '  Bdtrige  sar  klia.  uud  axp.  Qeh.  iind  fiju.'  8t«  Band,  8lc  Hoti,  &.  307, 
18B4. 


DdKINO    TBB    LTINO-IM    PERIOD. 


HI 


llie  whole,  in  pregnancy  was  58'2  cm.;  immediately  after 
delivery,  b8  ciu,;  Inttr  on,  84*1  cm.  The  average  girth 
Bt  the  nmbilicuB  he  found  in  twenty-two  virgina  to  be 
78"5  cm.;  in  113  primigravidro,  QB'I  cm.;  immediate]y 
after  delivery,  84'2  cm.;  in  the  lying-in  period,  80"5  cm. 
In  seventy-five  secuodigravidte  it  waa  97*5  cm. ;  imme- 
diately after  delivery,  85'9cm.  ;  in  lying-in  period,  83-1  cm. 
In  fifty  multigravidffl  it  was  98'2  cm.;  immediately  after 
delivery,  872  cm.;  in  lying-in  period,  83'2  cm.  The 
average  of  the  whole,  in  pregnancy  waa  96*5  cm. ;  imme- 
diately after  delivery,  86'S  em.;  in  lying-in  period, 
81-9  cm. 

In  eighteen  priraigravidfe  measured  by  Mr.  Pratt,  the 
citOumfereuce  at  the  level  of  the  ensiform  cartilage  aver- 
aged 30-9  in.,  OT  78*5  cm.  (Kebrer,  base  of  chest  81*7 
cm.).  In  eleven  maltigravidsa,  29'9  in.,  or  76  cm.  {Kehrer, 
base  of  chest  81-1  cm.),  it  averaged  midway  between 
ensiform  cartilage  and  umbiHcus,  32'8  cm.;  in  eighteen 
primigravidiB,  32*8  in.,  or  83'4  cm, ;  in  eleven  multi- 
gravidw,  32*5  in.,  or  82-5  cm.  Kehrer  gives  no  measare- 
ments  at  this  point.  At  ambilicas,  in  eighteen  primi- 
gravidee,  the  average  was  35*2  in.,  or  89-b  cm.  (Kohrer 
9b'l  cm.).  In  eleven  multigravidie  the  average  waa  33*7 
in.,  or  85*5  cm.  (Kohror  97*7). 

In  fifty-eight  primiparro  the  average  circnwiferenco  at 
the  ensiform  cartilage  on  the  day  following  delivery  was 
29*2  in.,  or  74-2  era.  (Kehrer,  third  day  73-D  cm.). 

In  seveoty  multiparte  the  average  circa mference  at  the 
ensiform  cartilage  was  2927  in.,  or  74"4  cm.  (Kehrer,  third 
day,  74-3). 

In  fifty-eightprimipane  the  average  ctrcumferenoe  mid- 
way between  the  ensiform  cartilage  and  the  umbilicus  on 
the  day  following  delivery  was  29'3  in.,  or  74-4i  cm.  In 
8cventy-ono  niultiparffi  the  average  was  30'6  in.,  or  77*8  cm. 

In  fifty-seven  primipune  the  average  circumference  at 
the  umbilicus  on  the  day  following  deliver}-  was  30*04  in., 
or  77"8  era.  [Kehrer  84-2  cm.).  In  sixty-seven  maltiparas 
it  was  81-10  in.,  or  7J»-2  cm.  (Kehrer  86-4  cm.). 


112 


TBE   RFriECT  OF  TBR   B1»DER 


Kobrer's  meastiroments  moetly  show  larf^er  dimeiiBions 
than  those  of  Mr.  Pratt..  This  maj  be  duo  to  racial  pecii- 
liaritiea  in  the  patienta,  tat  I  think  that  the  factor  which 
IB  probably  paramount  in  explaining  the  diSereuce  is  that 
Eehrer's  patients  came  from  a  small  town  and  its  rural 
neigh  bonrhood,  while  Mr.  Pratt's  had  many  of  them  been 
brought  np  in  the  poorer  parts  of  London. 

During  the  lying-in  period  these  measurements  dimi- 
nish. The  following  figures  show  the  average  lessening 
in  129  patients. 


AfUr 

(UUTorj. 

irtertoii 

wetk. 

DiminQtiinL 

At  level  of  ^naiforn  cart>l»g« 
Sfidway   between    eoBiform    ciirti1ag;e 

At  level  of  umbillou   .        .        .        . 

89-S 

8089 
80-91 

S8 
80-6» 

1-a 

1-S6 
1-S6 

Thi&  diminution  of  the  circumference  of  the  parts  bound- 
ing the  abdominal  cavity  eeema  to  me  such  aa  might  be 
expected  from  the  reduction  of  the  volume  of  the  abdo- 
minal contents  which  must  accompany  the  involution  of 
the  uterus. 

The  next  table  exhibits  the  difference  between  primi- 
parte  and  multiparas  ; 


DajttftDr  dBtlTcrr. 

Mtet  finl  ncek. 

DiBiiiiutiQa. 

Prluii- 

liani!. 

Uultl- 

Frinl- 

[■UK 

Mnlli- 

puw. 

Priml- 

UtUU- 

At  level  of  CDsiform  cartildge 

Mid^ray    botwecn     umbilical 
and  GptifariD  ciTtiUg^e 

At  level  of  ambiliciu     . 

29-2 

29-3 

80« 

28-27 

so-e 
ai-16 

88-1 
28-1 

87-9 

S9-8 
2fi-8 

1-1 

MS 
I'S 

X» 
1*8 

D-UEtNO    THE    LYIKG-IN    PEIIIOD. 


113 


The  differeBCB  between  primiparie  and  mnUfpane  is  so 
small  as  to  be  practically  nothing.  The  lower  meaBiire- 
ments  are  rather  greater  iu  muUipnrfe,  the  average  being 
probably  rtiiaed  by  the  greater  number  of  fat  patients  ia 
maltiparffl.  What  little  differonco  there  is  in  the  amount 
of  dimiDation  is  all  in  the  same  direction,  and  ehows  a 
greater  amount  of  diuiitmtion  among  the  multiparic. 

The  next  table  shows  what  difference  there  is  due  to 
age: 


Dif  liUrildlvinj. 

Afler  lint  weak. 

DiniinutlDB. 

Dndiii 
29-2 

Ota 

S6. 

Undor 

3g. 

Over 

n. 

tluder 

Otbi 

M  Wvel  oC  ontifonn  urtiU^ 

SO 

Sfi-OS 

SS'SS 

1-13 

1'12 

MidwRj  between  ciuifurm  car- 

2fl-2 

29-8 

2t-6 

2S'6 

1-B 

1-8 

At  tnnliiliciu  .        .        .        .'    306 

ai-5    23-1 

8!>-8 

1*5 

17 

Here  we  find  the  nieaBurements,  as  might  be  expected, 
rather  greater  amoug  the  older  pntients.  The  diflerencee 
in  the  atQOunt  of  diuiiaution  are  not  greater,  and  arc  not 
rogntarly  distributed. 

In  order  to  ascertain  what  part,  if  any,  the  binder  takee 
in  producing  or  modifying  these  changes  in  the  size  of  the 
chest  and  abdomen  duriug  the  lyiag-in  period,  the  follow- 
ing method  was  adopted. 

First,  a  number  of  patients,  taken  withont  eelection, 
were  measured,  as  to  whom  no  special  instniotiona  were 
given  to  the  nurses.  They  were  allowed  to  put  on  the 
binder  in  the  way  enjoined  by  the  rules  of  the  hospital. 
The  following  are  the  directions  giveu  to  them^ : 

"The  biudrr  should  consist  of  huckaback  towelling, 
thirty-«is  inches  wide  and  one  and  a  quarter  yards  long, 
doubled  lengthways.  Its  lower  edge  should  reach  four 
inches  b«low  the  top  of  the  thigh-bone  (great  trochanter). 


114 


THB    Smcr   OF   THE    BINDKE 


The  free  end  of  the  binder  should  He  uppermost  on  the 
right  Bide.  Starling  from  the  left  flank,  the  binder  should 
psEa  over  the  abdomen,  round  ths  bade,  and  »gaiii  over  the 
abdomen,  ending  on  the  right  flank,  where,  bfter  it  has 
been  tightened,  and  all  creases  smoothed  out,  it  ahoulil  be 
aeonrely  fastened  by  four  atrong  pins.  The  patient's  ekin 
should  be  guarded  by  the  left  hand  beneath,  and  the  pios 
inserted  in  the  following  order,  beginning  from  below — one 
at  the  lower  edge  of  the  binder,  three  inches  below  the  top 
of  the  thigh-bone,  and  a  second  a  similar  distance  below 
the  top  of  the  hip-bone,  both  fastening  the  hinder  tightly, 
serving  to  keep  it  in  positioD  and  preventing  it  from  riding 
up.  The  third  should  hold  the  biader  still  more  firmly  on 
a  level  with  the  top  of  the  womb;  and  a  fourth  near  the 
upper  edge  of  the  binder,  not  too  tightly  applied,  complete 
the  serioB."  Forty  patients,  to  whom  the  binder  was  ap- 
plied in  this  way,  were  mo&Eared. 

In  a  second  aeriea  of  patienta,  thirty-five  in  number,  also 
taken  without  selection,  no  binder  at  all  was  applied,  or 
if  a  patient  were  discontented  at  its  abeence,  a  binder  was 
put  loosely  roand^  care  being  taken  that  it  should  not  be 
tight. 

In  tk  third  series  of  cases,  instructions  were  given  that 
the  binder  should  be  applied  as  tightly  as  possible,  and  the 
house-surgeon  at  each  of  hia  visits  made  a  point  of  ascer- 
taining that  it  was  tight,  and  of  tightening  it  to  the  atmost 
of  hia  power  if  it  were  at  al!  loose. 

TheBG  three  classes  of  patients  are  denoted  in  the  tables 
which  follow,  as  those  with  ordinary  binder,  no  binder, 
and  tight  binder. 

In  these,  and  tn  the  measurements  in  which  patients  of 
different  ages  were  compared,  the  greatest  differences  are 
between  the  abdominal  measurements.  It  is  in  the 
measurements  of  these  parts  that  the  greatest  variations  may 
bo  expected  to  occur,  not  only  from  the  varying  amount 
of  gaa  in  the  bowel,  but  from  the  looseuese  of  the  parietea, 
which  renders  it  easy  to  make  the  measurement  half  an 
inch  more  or  tees  without  a  groat  difference  in  the  tight* 


1 

^^^^^^        DUBIKa    THE!    LTINO-IK    PERIOD.                             llS 

VaiienU  wiih  orHina.'nj  binder  (39  iu  niimh^r). 

^H 

McHunmciils. 

Afler 

•tta. 

DiminnliiiB. 

I.  At  etuiform  curtilnge 

t,   Uidwny  Wtween  eniifariii  I'urtilugo 
and  umbilieai      .... 

zy-s 

31 '6 

S8-S 

88-6 
29-9 

1-1 
1-7 

k 

K          Patimts  without  hinder  (S5  in  numler). 

HaMBmnatiUi. 

itta 

dsUTOiy. 

Sine  ian 
bfttt. 

DiminutiDU. 

L  At  QtuifariD  oartilajtp                     . 

S.  Uidwftir  iMtwreii  onuifurin  cartiliMcii 
itnd  umbllicn*      .... 

29-3 

29-2 
SO'I 

SB-l 

S8 
S9-4 

1-2 

1-2 
0-7 

k 

H          Patient*  with  firm  hindfr  (48  w  nitmher). 

' 

Utimireniciii* 

After        1    Nine  djijt 
dtfUxerjr.               mtiat. 

1 

OiniiiDllDu. 

J 

1.  Al  fnnirariD  cartilm^ 

2.  Midway  between  eniifofni  eartilH^^a 

andntnbilieaf)      .... 

S8-9 

1S8-S 
89-5 

87*8 

27-8 
2fl 

It 

1 
0-S 

1 

I , 

J 

U6 


THE    RvrWT   Of    TH£    BtNDXS 


neB8  of  the  measure.  In  the  two  circumferenceB,  wliioh 
are  easy  to  lueaaare  and  do  not  vary  from  hoar  to  iour,  tlie 
figures  show  that  the  diminotion  during  the  lying-in  period 
was  the  sarae,  whether  the  binder  were  applied  firmly  or 
loosely  or  not  at  all. 

MeaBuremeutB  have  also  been  moide  for  me  by  Mr.  Fowler 
and  Mr.  Pratt,  to  ascertain  the  extent  to  which  the  lower 
part  of  the  cheat  could  be  compreaaed  by  the  measuring 
tape.  The  amount  of  dimiuatioQ  practicable  in  the  majo- 
rity of  cases  was  between  3^  and  5  inohes.  The  maximum 
diminution  observed  was  9|  inches.  (This  was  in  a  patient 
aged  twenty.three,  who  measured  SSJ  inches  round  the 
lower  chest,  reducible  by  compression  to  29.)  The  amount 
of  diminution  ie  80  much  iuBuenced  by  the  extent  to  which 
the  patient  lends  herself  to  ib  by  relajiing  the  mu&olee 
which  expand  the  chest,  and  also  by  the  amount  o£  pull- 
ing, that  I  do  not  think  the  compilation  of  averages  from 
theee  figures  wilt  yield  results  of  value. 

The  general  conclusion  that  I  come  to  is  this :  That  con- 
sidered as  a  means  of  keeping  the  waist  small,  a  binder  of 
the  ordinary  kind  has  not  the  slightest  effect. 

I  do  not  question  the  comfort  it  affords  the  patient,  nor 
argue  agaiust  its  use  as  a  means  of  giving  comfort. 

I  do  not  doubt  that  by  the  pereistent  nee  of  an  onyield- 
ing  belt,  which  can  be  pulled  tight  and  kept  tight  by  straps 
and  buckles,  the  base  of  the  chest  may  be  compreaaed 
during  the  lying-in  period  as  well  as  at  other  times,  and 
that  by  the  sufficiently  prolonged  use  of  such  appliances 
permanent  deformity  of  the  chest  may  be  induced,  or  de* 
formity  preiseut  before  pregnancy  maintained. 


Di'.  OBEVta  Gdid  that  hu  bad  not  found  that  putionte  desired 
a  btlt  from  any  idea  that  it  could  inSiiencc  thf  anc  of  the  waist, 
Thev  wished  for  a  belt  bpcause  of  the  support  which  it  gave 
to  th>3  Iow«T  abdomen  aad  for  its  effect  in  checking  any  future 
tendency  to  undue  fuliiees.  He  certainly  thought  also  that,  if 
the  belt  were  adjusted  at  the  begiiiuing  of  labour  and  tightened 
team  time  to  time  during  its  progrese,  tt  had  a  diBtinct  iiLfluenc« 


DDfiINO  THI   LTINO-IN  n&tOti. 


117 


in  promoting  uterino  action  and  lesaening  any  touduacy  to  sub- 
sequeat  beemorrboge. 

Dr.  Chamfnetb  said  he  was  unable  to  agree  with  I>r.  Herman's 
coaelosioQ  that  the  only  use  of  the  biinlorwas  the  comfort  of  the 
patient,  anlesa  th«  word  comfort  were  allowed  a  very  wide  eu^pe. 
The  usee  of  the  binder  were  best  exeiuplified  by  the  occaaioual 
consaqueneea  of  its  absence, — in  a  word  •'  pendulous  belly." 
Bendolous  belly  was  not  a  mere  Eeathetic  defect,  but  a  condition 
asBOOated  with  serious  tods  of  health,  and  with  diatressing  aym- 
ptolDB.  8Ucb  aa  constipatiou,  pain  in  the  abdomen,  and  other 
thin^,  and  he  belicTcd  that  the  pendaloua  belly  was  the  cause 
of  the  symptoms  and  uot  merely  an  effect  due  to  a  cause  common 
to  both.  The  UHe  of  a  binder  was  to  keep  t]ie  abdominal  walls 
in  a  favourable  condition  and  position  during  th^  iurolation 
which  they,  in  common  with  other  etmctures  hypertrophied 
during  pregnancy,  should  undergo  during  the  lying-in  peiiod. 
The  8ofl  parts  of  the  pelvia  underwent  similar  hypertrophy  and 
similar  inrolution,  and,  in  their  case,  the  recumbent  position 
aUoved  them  to  undergo  this  in  a  proper  position,  wiiilc  the 
action  of  gravity  (too  early  getting  .up)  interfered  with  this  action 
and  promoted  descent.  Aa  regurded  the  "figure,"  that,  no 
doubt,  meant  one  thing  in  the  cuae  of  a  woman  whose  reputation 
depended  npon  her  being  able  to  get  into  acventeeu-iiicli  slays, 
and  another  thing  in  the  ca&e  of  a  sensible  doctor.  The  latter 
probably  meant  a  well-braced  abdom«u,  With  regard  to  the 
Oompreasiou  of  the  hypoclioudria,  Dr.  Cbanipueya  was  glad  to 
hoar  that  this  could  uot  be  brought  about  by  the  binder,  but  Im 
thought  that  A  binder  should  not  extend  so  high  as  to  coiii]>ri;t8 
the  hypochondria.  Binders  were  not  commoniy  used  in  (Jermuuy, 
and,  in  bis  experieuce,  Eugliah  hospital  patients  recovered  with 
hotter  figures  thaa  German  women,  while  private  patienta  who 
had  eiperieoced  English  and  tierman  oustomti  preferred  thv 
former.  He  i^uite  agreed  with  Dr.  Hermnn  that  the  bindi^r  did 
not  prevent  flooding;  thu  uterus,  if  incliued  to  relax,  disregarded 
the  binder. 

Dr.  Braxtom  Hicks  referred  to  a  paper  published  in  the 
•  Proceedings  of  the  Medical  Society  '  some  few  years  siDce,  under 
the  head  of  Variations  of  Abdominal  Tension,  m  which  the  ques- 
tion of  the  binder  had  heen  alluded  to,  and  other  poiiits  fully  dis- 
cussed. But  be  oould  not  thoroughly  endorse  tiiestateuKiiuts  of 
thfl  previous  spoalrers  in  regard  to  the  UBeleasneas  of  the  binder 
on  the  ba»(.'  of  thorax.  It  wils  cleiLr,  from  the  facta  collected  by 
the  author,  that  the  base  of  tbe  thorax  was  expanded  by  the 
pregnant  uterus.  This  being  bo  after  delivery,  the  abdominal 
walln  were  unable  by  so  much  ae  they  were  elevated  to  apply 
their  pressure  on  the  abdominal  contents — blood  therefore  flowed 
into  tlio  abdominal  cavity,  ready  to  flow  into  the  uterine  cavity 
■LouLd  the  walls  of  this  oi^an  become  atonic.     Dr.  Hicks  com- 


118 


THI  SmCT  OF  TSa  BINDBE,  BTC. 


pared  the  state  of  the  thorai  after  delivery  to  that  a/t^r  flxpan- 
aioa  by  very  large  oraxian  cysta,  where,  aifcer  tapping,  the  baa© 
o£  tlie  thorax  waa  so  expaaded  that,  until  a  firm  strap  had  been 
applied  around  the  patient,  she  waa  uDa3)le  to  breathe  or  cough. 
Hethought  that  if  the  thontiwero  brought  to  its  natural  size  by 
a  slight  bauJage,  it  would  be  benefidal- 

Mr.  Alban  Dohait  renutrked  that  Dr  Herman  had  not  defined 
what  waa  precisely  understood  by  the  term  "waist."  la  the 
days  of  Queen  Elizabeth  tbe  waist  of  the  drees  wa.s  as  low  as 
the  hipa,  the  body  being  joined  to  the  skirt  almost  along  the 
line  of  the  cniml  arch.  At  the  beginning  of  this  century  the 
waist  lay  nearly  as  high  as  the  axillro.  What  women  really  and 
naturally  objected  to,  after  child-bearing,  was  eala.rgeiuen.tof  the 
abdomen  which  looked  unaightly  whererer  fashion  might  place 
the  "waist."  A  pendnloua  abdomen  suggested  mature  years; 
moreover,  it  gave  rise  to  much  physical  discomfort. 

Dr.  HoBUAN  said  that  his  statements  only  applied  to  the 
binder  in  ordinary  use,  put  on,  as  was  usiiaJ,  after  labour,  and 
not  to  the  abdomioal  bandage  as  an  adjuvant  to  labour.  By 
"  waist "  be  understood  the  smallest  circumference  of  the  trunk, 
and  this  he  thought  in  the  preseat  style  of  dress  lay  usually  over 
the  lower  ribs.  Although  attaching  weight  to  Dr.  Champneya'a 
impreBgion  as  to  tha  grejiter  frequency  of  pendulous  belly  in 
Qermiui  women,  yet  he  did  not  think  tb^it  it  bad  been  proved, 
or  was  absolutely  certain,  that  this  greater  frequency  did  exist. 
If  it  did,  it  might  be  accounted  for  by  other  conditions  besides 
the  absence  of  the  binder.  Women  were  commonly  discharged 
from  German  lying-in  hospitals  sooner  than  they  were  in  this 
country,  aad  possibly  resumed  their  boueeh'^td  duties  sooner.  He 
could  not  see  how,  while  the  patient  was  lying  in  bed,  there  could 
be  much  strain  on  the  abdominal  muscles  either  from  gravity  or 
any  other  cause;  and  it  was  while  the  patient  lay  in  bed  that 
the  biuder  waa  worn.  He  could  have  understood  the  efect  of  a 
belt  worn  after  the  patient  got  up  m  prtivonting  ponduloua  belly  ; 
but  that  woe  not  here  under  consideration.  His  figures  showud 
that  the  binder  bad  no  appreciable  effect  in  the  abdominal 
measurement.  It  was  not  his  wish  to  dissuade  anyone  from 
using  the  binder.  Dr.  Herman  believed  that  the  comfort  that 
it  gave  was  a  sufficient  rea&oa  for  using  it.  But  the  binder  was 
not  necessary,  and  was  not  a  safeguard  against  any  subsequent 
trouble ;  and  he  thought  that  medical  men  might  be  guided  as 
to  its  iwe  entirely  by  the  wishes  of  their  patients. 

Dr.  CB&MPHEVSHaid  that  he  bad  not  alluded  to  gravity  except 
in  regiird  to  the  pclviu  organs. 


APOPLEXY  OF  THE   OVARY;    CYSTIC    DILATA.- 
TICK  WITHOUT  RUPTIJEB. 

By  Alban  Dohan. 

mtOMK  TO  THB  SUUSIZaV  nUB  UCMnTAL. 

(BflMiivod  Novembar  SLst,  1889.) 

[Ahilrael.) 

Th8  patient  was  34  years  old,  and  had  borne  ei^bt  children. 
The  alHlomcja  vraa  uuusuallj  diBtended  duriog  her  seventh 
ppegnanty  (1886).  It  riiiiiiUDfsil  large  till  the  conclusion,  at 
term,  of  her  eighth  preguAQC^  !□  th«  eummer  of  1888.  The 
abdomiual  distention  continued.  In  April,  1889,  she  was  sud- 
denly attacked  with  severe  pain  over  the  right  B.ide  of  the 
abdomen.  Four  weeka  later  the  abdomen  was  found  distended 
by  a  globose,  elastic  and  truely  movaable  tumour,  which  pressed 
dowDwards  into  Douglas's  pouch.  Early  in  S<.*pti<mb^r  the 
tumour  suddeoty  diminiahud  in  size,  sinking  into  the  pelviB.  On 
October  2Srd  Mr.  Kuowaley  Thornton  operated.  The  tumour 
woa  romoved ;  it  proved  to  be  thw  right  ovary  converted  into  an 
oral  body,  two  and  a  half  inches  in  its  longest  diatUBter,  and 
with  an  irr^nlar  surface  of  a  uniform  dull  drab  colour.  The 
ntonuftud  left  orary,  the  abdominal  vificera,  and  the  pentoneuin 
showed  no  sitfua  of  disease  old  or  recent.  The  ovary  formed  a 
cyst  fiU«d  with  a  ytillow  mass,  which  was  found  to  be  old  clot. 
A  Urge,  woll-form»d  corpus  luteum  opened  out  into  the  cavity 
containing  tbo  clot.  The  cyst'Wall,  one  vightb  of  an  inch  thick, 
consulted  of  normal  orarian  tissue  bearing  a  few  follicles.  The 
patient  oiade  a  good  recovery.  The  attack  of  pain  in  April,  1889, 
probably  roprosonted  the  nipture  of  a,  mature  follicle  into  tho 
stroma.  The  ovary  then  griuluaUy  distended  till  the  hnmorrhage 
oeas«d,  and  diminished  in  bulk  as  the  clot  contracted. 


^ 


120 


APOPIBIT  O?  THB    OVAEY. 


The  varieties  of  apoplexy  of  the  ovary  are  described.  Thia 
caae  IB  &a  example,  uot  of  hemorrhage  confined  to  tli«  cavity  of 
a  dilated  follicle,  nor  of  htemorrbage  ori^atiug  iu  tho  etroma, 
but  o£  hismorrbage  into  the  stroma  through  rupture  of  a  follicle. 


Mra.  0.  C — ,  aged  34,  a  healthy -loolciug  woman,  short 
in  stature  and  inclioed  to  corpulence,  was  admitted  into  Mr. 
Boiowgley  Thornton's  warda  in  the  Samaritan  Free  Hospital, 
in  October,  1889. 

She  had  been  married  for  eeventeen  years  and  borne 
eight  children,  the  youngest  was  over  foarteou  moutlis 
old.  The  catamenia  appeared  at  fourteen  if  not  earlier, 
and  continued  regular  except  during  pregnancy  and  lao- 
tation.  In  the  course  of  her  seventh  pregnancy,  in  1886, 
the  abdomen  grew  unusually  large,  bub  she  suffered  no  pain. 
On  September  9th,  in  that  year,  she  gave  birth  to  a  very 
large  child  and  a  "false  conception"  aUo  came  away, 
according  to  her  doctor's  Etatment.  On  recovery  she  felt 
quite  well,  but  observed  that  the  abdomen  was  almost  as 
distended  as  when  pre^nnnt  at  full  term.  One  yeai'  and 
ten  mouths  later  the  patient  gave  birth  to  a  smaller  child 
(her  eighth),  Tliroughout  this  pregnancy  she  was  never 
as  swollen  as  in  1886.  After  delivery,  the  abdomen  re- 
mained distended!.  In  April,  1 889,  ahe  was  suddenly 
attacked  with  severe  pain  in  the  right  side  of  the  abdo- 
men, and  called  iu  a  practitioner.  At  the  end  of  May 
Bhe  conaalted  Mr.  F.  W.  Morisoo,  stating  her  behef  that 
ehe  had  a  tumour  and  was  as  big  ^  at  term.  The  size 
of  her  abdomen  prevented  her  from  doing  heT  household 
duties  and  defeecation  waa  painful. 

Go  examination,  the  abdomen  was  found  distended  aa 
at  about  the  seventh  month.  The  umbilicus  protruded. 
The  hypogastric  and  umbilical  regions  were  occupied  by 
B  globose,  elastic  and  freely  moveable  tumour,  dull  on  per- 
cussion and  "  distinctly  fluctuating."  The  right  flauk 
WH  resonant,  the  left  dull  on  percusBion.  The  cervix 
uteri  was  high  id  the  pelvis  uud  pushed  forwards.  The 
poaberior  fornix  was  ocoupied  by  a  rouud,  olastio  swelling. 


APOPLEXY  OP  TSr  OVABT. 


121 


convex  towards  the  vagioa  and  continuous  with  the  abdo- 
toinal  tumour. 

Early  in  June  the  patient  was  taken,  to  the  Kamaritan 
Hofpitalj  where  Dr.  Amaud  Iloiith  and  Mr.  Thoratou  exa- 
mined her.  OrariiiQ  cystoma  was  suspected.  She  re- 
turned homo,  to  await  hef  turn  for  admission  into  the 
hospLtal.  At  the  liegiiming  of  September  she  infoTtned 
Mr.  MorisoQ  that  a  few  days  previously  she  discovered,  on 
getting  out  of  bed,  thfit  her  abdomen  had  suddttuty  dimin- 
ished in  size.  Mr.  Morieou^xauiiiied  her,  and  found  that 
the  abdominal  tumoar  had  quite  disappeared  ;  resonance 
was  uuiversal  within  its  normal  limite,  and  tlia  abdominal 
iralU  were  flaccid.  On  vaginal  examination,  a  mass  the 
aizd  of  a  billiard-ball  was  felt  high  up  in  the  region  of 
the  right  broad  ligament.  Tbia  maaa  was  QOt  tender  to 
touch,  and  caused  no  pain.  The  patient's  health  steadily 
improved. 

The  patient  was  admitted  in  October,  just  six  monthi 
after  the  sudden  attack  of  pain  which,  as  the  sequel  will 
ghow,  probablv  represented  the  beginning  of  her  illness. 
The  clmical  history  was  complicated,  jet  most  important 
in  relation  to  the  pBthnlogy  of  the  case.  Fortunately, 
Mr.  Mnriflon  preserved  the  notes  which  ho  took  during 
the  progress  of  the  patienfs  illne^ft,  and  kindly  sent  me  a 
copy,  of  which  I  have  availed  myself  in  the  above  report. 
The  remainder  of  the  case  camo  under  my  own  observation. 

On  admission  the  patient's  abdomen  whh  found  to  be 
digtcuded  by  fat  in  the  parictos  and  by  Sntus,  but  no 
tninour  could  h&  detected.  There  was  tendovnesB  over 
the  iliac  fosste.  The  os  nteri  was  large  aud  flabby,  the 
sound  paiasedinfor  two  and  a  bulf  I»che8.  Ou  the  right 
side  and  in  front  was  a  mass  "  the  »izo  of  a  smull  orange," 
freely  moveable  and  tender.  The  last  period  began  on 
September  23rd,  1889. 

Mr.  Thornton  opornted  on  October  28rd,and  I  had  the 
advantage  of  atJeiKtiug  him,  eo  that  I  was  enabled  to  note 
the  relations  of  the  tumour  and  the  condition  of  tho  parte 
exposed.      An  incision  thrco  and  a  half  inches  in  length 

VOL.  xxziu  9 


122 


APOPLKXT    OF   THB    OVAFY. 


was  made  through  fat  parietaa.  An  oval  body  was  at  once 
drawn  ont  of  tlie  incision  witliout  any  difficulty^  ae  there 
wereno  adbesioDB.  This  body  liad  a  singular  appearance, 
Bomewhat  reeembliug  a  boiled  suet  dumpling,  and  at  lirst 
was  suspected  to  be  a  pedunculated  subperitoneal  fibro- 
myoma,  but  its  pedicle  vvils  found  to  consist  of  the  right 
Fallopiai)  tube  and  broad  ligament.  The  uterus  was  large 
ftnd  soft.  The  left  ovary  was  healthy  and  succulent,  and 
contained  a  large  ripe  follicle  ;  it  was  not  removod.  The 
parietal  and  riseeral  peritoneum  appeared  perfectly  normal. 
The  patient  luado  a  good  recovery. 

The  tumour  consisted  of  the  right  ovary.  It  weighed 
two  ounces,  and  measured  two  inches  and  a  half  in  vertical 
diameter,  and  one  inch  and  five-eighths  horizontally.  The 
surface  was  of  a  dull  drab  colour,  and  puckered  eo  as  to 
present  convolutione  like  the  brnin  of  one  of  the  lower 
mammalia.  This  appearance  is  not  rare  in  the  big  succu- 
lent ovaries  of  healthy  young  raamed  women.  When 
cut  across,  the  interior  was  found  to  consist  of  a  spongy 
lemon-coloured  Bubstanee,  the  ovarian  tisaue  foiining  a 
cortex  one^eighth  of  an  inch  thick.  The  cavity  contain- 
ing the  substance  bore  a  translucent  lining  membrane  ;  at 
the  uppermost  part,  nearest  the  attachment  of  the  bvnad 
ligament,  wan  a  thick  piece  of  membrane  forming  Bigzng 
folds,  evidently  the  remaius  of  a  large  corpus  liiteum. 
TIlh  appearance  of  the  interior  of  the  ovary,  as  seen  when 
the  specimen  wae  fresh,  iawell  represented  by  Mr.  Lewin's 
coloured  drawing. 

The  brond  ligament  bore  an  acocBBOry  fimbria  on  a  long 
pedicle,  which  had  become  soparntod  from  the  Fallopian 
tube.  Two  Graa6aii  follicles  projected  from  the  surface 
of  the  ovary  near  llie  iitLaclmient  of  the  broad  ligament. 
Both  were  much  dilntud.  One,  half  an  inch  in  diameter, 
contained  altered,  almofit  decolourispd  clot  ;  tlie  other, 
one-third  of  an  inch  in  diatneterj  contained  white,  slightly 
glairy  fluid. 

After  the  coloured  drawing  of  the  specimen  had  been 
taken,  the  two  halves  made  by  a  section  to  expose  tho 


APOPIiBIT  or  THE  OTART. 


inierior  of  the  ovary  wore  placed  for  a  few  days  in  a  weak 
Bolutiou  of  spirit.  At  tlie  eod  of  that  period  I  found  an 
opportunity  of  GxamiQiu^  the  specimen  more  iiiiuutclv. 
A  large,  Bingle-ctambered  cavity  occupied  the  ioterior  of 
the  orary.  It  was  filled  with  the  tougli  yellow  Bubebanco 
already  described.  The  membrane  in  zigaag  folds  was 
deficient  towards  tlie  yellow  Bubstanee,  bo  that  it  partially 
enclosed  a  space  (roBembliDg  in  all  respects  the  cavity  of 
a  well-formed  corpus  luteuin)  which,  where  not  bounded 
by  the  membrane,  opened  out  against  the  yellow  suhistanee. 
On  removing  the  substance  from  the  cavity  in  which  it 
was  embedded  in  one  of  the  half-sections,  the  space  par- 
tially enclosed  by  the  zigzag  membrane  waa  found  to 
7en  out  into  that  onTity.  The  above  appearances  indi- 
cted the  rupture  of  a  mature  follicle  into  the  stroma, 
with  sobsequent  hemorrhage. 

The  lining  memhrane  of  the  cavity  which  contained 
the  yellow  sttb»taiice,  translucent  when  fresh,  became 
opaque  after  the  immersion  in  spirit.  The  meuibraue 
was  soft  aud  homogeueous  ;  it  was  apparently  haU>or> 
ganised  fibriue.  Mr.  Targett  carofully  esamiDed  the 
yellow  Bubatance,  and  found  that  it  consisted  solely  of  clot, 
with  no  appearance  of  oriranization.  The  general  appear- 
ance of  the  diseased  ovary  and  the  relations  of  the  corpus 
luteum  to  the  cavity  indicated  a  pathological  ooudition 
which  bore  no  relation  to  incipient  cystoma  of  the  organ. 

No  rent  nor  cicatrix  of  a  rent,  nor  any  aperture  nor 
fifltuloits  track  could  he  detected  on  tlie  surface  of  the 
ovary.      The  two  dilated  follicles  bore  no  cicatrices. 

The  appearances  above  described  render  an  esplana- 
tioQ  of  the  clinical  Kymptoms  simple.  I  attach  but  little 
importance  to  the  history  of  the  patient's  seventh  and 
eighth  pregnancies.  The  sudden  attack  of  pain  in  April, 
1889,  indicated  the  rupture  of  a  mature  follicle  into  the 
ovarian  stroma.  The  conseciurut  dislentioQ  of  the  ovarj- 
would  necessarily  entail  much  Buffering.  Through  some 
obBcur©  cause,  probably  morbid  softening  of  the  stroma, 
hfcmorrhage  took  place  and  continued  for  some  time  nn- 


124 


APOPLEXY    or   THE   OVABIT. 


cljecked,  Tha  ovary  became  Bwollen  ao  aa  to  form  a 
tuTUOLir  apparently  tlie  size  of  a  fcetal  head.*  The  Biirface 
oi  tlie  ovary  failed  to  burst,  the  hiemorrhage  ceaaed,  and 
therefore  tLe  distention  ceased.  A  coagulum  formed 
witLin  the  ovary  and  contracted,  so  that  tlie  pain  dU* 
appeared  and  the  swollen  organ  steadily  became  enaaUer. 

Thus  the  appearance  of  a  tuuiour  in  May,  18S9,  Homo 
time  after  the  attack  of  pain,  ia.  readily  explained.  The 
tumour  was  tlie  ovary.  It  could  not  very  well  have  been 
blood-clot  free  in  the  peritoneum.  Ruptur*  of  the  right 
ovary  seems  out  of  the  question  in  thia  case,  and  hiemor- 
rhagc  from  a  burst  follicle  in  the  left  ovary  may  be  Bet 
aside.  Free  bleeding  into  the  peritoneum  would  have 
caused  faintuoss  rather  than  aevere  pain  ;  but  the  patient 
laid  stress  ou  the  fleverity  of  the  pain  in  April,  and  does 
not  appear  to  have  felt  faint.  At  the  operation  the  peri- 
toneum showed  no  abnormal  appearances  of  any  kind. 
Had  the  tumour^  detected  in  May,  consisted  of  a  large 
circumscribed  collectiou  of  blood  in  the  peritoneum,  some 
trace  of  tho  effiiRod  blood  would  certainly  have  been  found 
during  the  operation  ia  October.  There  remains  no  other 
explanation  of  the  tumour  which  appeared  in  the  spring 
of  188i>. 

The  specimen  illustrates  the  condition  knowu  to  patho- 
logists by  the  oonveniect  name  "apoplexy  of  the  ovary." 
Authorities  bo  high  as  Beroutz  and  Goupil  have  already 
ju&tified  the  nse  of  that  term.  They  speak  of  a  hsemor- 
Thagic  softening  which  resembles  a  similar  condition  pre- 
ceding cerebral  apoplexy.  The  term  "apoplexy"  is  gener- 
ally intended  to  imply  rupture  of  the  ovary  through  the 
hsemorrhfige,  but  Wiiickel,  one  of  the  latest  writers  ou  the 
subject,  applies  the  term,  in  his  '  Diseases  of  Women,'  to 
the  earliest  or  mildest  forms  of  the  condition  in  question. 
"  The  hypertBUiia  of  the  ovaries  which  accompanies  men- 
strual congestion  may  be  so  greatly  increased  by  external 
causes  that  not  rarely  a  follicular  haemorrhage  as  large  as 

*  Th»  sbdouittml  wnlLi  uere  tut,  lo  tbat  tlis  tumour  probnlily  felt  larger 
lliati  it  rrnllj  was. 


125 


a  cherry  may  be  found  in  the  ovary,  This  apoplexy  may 
affect  a  number  of  foUicUs  simultaneonsly."* 

Ovumn  apoplesy  with  rupture  neoeasnTily  iavolvca 
lifBuifttocele.  It  is  a  rare  and  very  fatal  condition.  Dr. 
Matthews  Dnnofin  informs  me,  "  I  httve  s»eu  a  fatal  case 
o(  burst  ovnrinn  cyst,  do  bigger  than  an  orangQ.  It  never 
came  to  a  formed  bBematocelo,  as  tho  woman  was  found 
dead  or  just  dying.  HoMuorrhage  evidently  made  it 
burst. "  The  "cyst"  was  apparently  of  the  same  cha- 
racter as  in  the  present  specimen.f  Bernutz  and  QoupilJ 
describe  several  cases  of  ovarian  apoplexy  with  rupturcj 
but  the  clinical  reports  {repeatedly  quoted  by  British  and 
American  writers  from  those  two  authorities)  arc  second- 
hand,  and  suffer  SBrioualy  from  want  of  diagrnma.  These 
remarks  espGcially  apply  to  Puech's  case,  which  occurred 
in  days  when  not  only  tlio  pathology, but  alsothdauatouy 
of  the  ovary  were  very  imperfectly  nuderstood.  Indeed, 
Bernutz  aud  Ooupil  display  a  wholesome  scepticism  on 
some  of  the  pathological  reports  which  they  publish.  In 
all  the  cases  which  they  quote,  however,  there  wns  clearly 
rujiture  of  the  ovary  from  heemorrhoge. 

Ovarinn  apoplexy  without  rupture,  as  in  the  present 
specimen,    has    been    well    described    by    Wiiickcl    aud 

'  i^iiicc  this  |inper  nui  written  laf  itttoutlou  hai  boon  tariicd  lu  u  good 
■atnmur;  of  ll>c  wliplo  aiibjoct  of  gvuiiitii  liicinotTba^c  Kij'  Vt.  F.  JtoUiu 
('  H^inarrlingiM  dci  OvwrM,"  Piirm,  HU-iiilirit,  1889). 

t  Sco  alto  ft  MIC  recorded  by  Dr.  W.  Brourii,  of  M«lrOM,  trhoro  a  woman, 
afftA  id.  ilii^il  «uiJJ«iily  on  ttio  ovo  of  her  marring^.  Tba  hiuuiorrliiteu  ws« 
tnwed  to  the  left  ovary,  whivLi  wai  "  Dunrly  tliu  Kiio  of  a  tiirkpy'R  egg" 
('Bdin.  Ucd.  •Tourn.,'  vol,  i,  1856-6,  y.  Si'i).  Still  luorv  intcrulinifi  in 
rolntinn  to  tli«  i>r«ieiil  caw,  !■  Dr.  AleiandfiT  T)ioium)ii'«  "  Noti^  of  it  Ciuu  uf 
Itoptwo  of  ill*  OvBry  folbwinj  Abortiaii "  (ibid.,  vol.  iv,  1868-fl.  f.  6(H), 
Tilt  patient  wm  forty  ycnrx  oI<I,  anil  nbartud  nt  tlir  m-rond  month.  TlircL' 
if«vhii  tntt^r  tymptomi  of  intra -peri  Ionian  I  bnmorrha^  oecurrod  and  prav(^d 
tiUl.  "Tliu  riicbt  orary  wm  found  to  liuvc  iia^tiiinod  a  tiauar  rupturu 
tbrou^out  it*  entirp  Icii^h.  The  ovHry  wn»  isut  iticri-iued  in  length,  and  its 
tcxlarc  uppcnrcd  bcnlthy,  with  tbe  osovption  of  alight  indnnttwa  ut  ono 
cstiVDity." 

{  ••Clinical  Mcnoif*  on  the  DitniuM  of  Women,"  Dr.  Mvndow*'  trsuiU- 
Uon.  Now  ijydcDbam  Society,  1S60,  vol.  i,  p.  IfW. 


APOPLEXT   or    THE    OVAKT. 


OUhanseri.  The  forraei-  has  observed  great  dist-ention  of 
the  follicles  from  effaaed  blood  without- "  any  extravasation 
of  blood  into  the  stroiuft  "  iu  three  aubjeota  after  death 
from  petroleum. burns  ;  in  two  after  phosphorus  poison- 
ing ;  \-o  three  after  typhoid  fever ;  in  one  after  cerebral 
apoplexy  ;  oue  after  tuberculosis ;  and  one  after  death 
from  cardiac  diseaee. 

OUhauaeu,  in  his  exceUent  'Krankieiten  der  Ovarien,' 
divides  ovarian  apoplexy  into  two  varieties^  hEsmoiTbage 
into  the  follicles  and  hsemorrliago  into  the  stroma.  In 
pare  examples  of  the  second  variety,  which  follow  local 
congestion  and  are  seen  as  complications  of  scurvy,  typhoid 
and  other  fevers,  the  stroma  becomes  converted  into  a 
spongy  snbetaace  full  of  fluid  blood,  roaembliug  the 
spleou. 

Th«  present  specimen,  as  proved  by  the  appearances 
which  I  have  above  described,  is  an  e:(atiLplc  of  ovarian 
apoplexy  originating  in  a  follicle,  but  involving  the  stroma 
through  rjptureof  the  follicle.  Olshausen,  who  recognieee 
this  secondary  form  of  haemorrhage  into  the  stroma,  de- 
scribes an  apparently  similar  case.  "  Whilst  small  apo- 
plexies disappear,  as  a  rule,  through  reabBorption,Bnd  leave 
no  trace  behind,  large  effusions  may  lead  to  the  partial  or 
complete  destruction  of  the  parenchyma,*  involving  in  the 
latter  caso  the  convuraioii  of  the  ovary  into  a  single  cyst, 
Qlied  with  a  thick,  greasy  mass.  In  the  courae  of  a 
necropsy  I  recently  came  across  this  condition  by  acci- 
dent. The  ovary,  lying  in  its  natural  position,  was  aboat 
three  times  its  normal  ^ize.  The  outer  wall  waa  thick,  no 
tiace  of  the  stroma  remained,  and  tte  contonta  formed  a 
very  thick,  greasy,  browniBh-yellow  mass." 

Hiemorrhage  into  the  follicles,  Olshauson's  first  variety 
of  ovarian  apoplexy,  must  often  be  overlooked.  TJnless 
every  Follicle  be  involved,  it  ia  hard  to  believe  that  it 
necessarily  destroys  the  functions  of  the  ovary.      Heemor- 

*  OUhauacii  tlooa  iiot  Atuto  wli«t)iur  tliii  ia  caused  by  pTonturc  of  tbe  blood 
within  an  unruptured  folliRle,  nr  bjt  I'ttniTnBn.linn  Into  tlic  itrDmn,  lu  in  th* 
tnutoat  cuk. 


APOPLBST  0?  THE  OTART. 


127 


rhage  into  the  stroma  is  more  serious,  and  may  end  in 
rupture  of  tTic  orgaij.  The  present  specimen  represents, 
therefore,  a  relatively  mild  and  secondary  type  of  that 
variety  of  apoplexy  ;  yet  at  an  early  Btago  of  the  case 
ruptnro  of  the  ovary  must  bave  been  imminent.  Ovarian 
apoplexy  is  uodoubtedly  uue  of  the  chauges  [if  not  the 
principal  ohange)  which  destroys  the  functions  of  the 
oruries  during  attacks  of  certain  acute  diseases  already 
epeciGed. 


Dr.  AjtfAHD  RocTH  could  not  agree  with  Mr.  Dorau's  csplan- 
utioii  of  tbiei  viiae.  In  May,  1889,  the  tumuitr  was  a.  Iluctiuiting 
vyBt,  leiicbLui^,  as  bimanual  palpation  plaiDljr  iudicnted,  from 
Douglas's  poiacli  to  tho  uinbUicTia.  In  September  it  suddenly 
diminished  in  eine;  itnd  wbon  bo  aavr  her  tigaiu.  early  in  October, 
only  a  hnrd  body  tbe  size  of  a  amall  orange  could  be  felt.  It 
mu  difficult  to  )>)'lieve  that  the  (lyat  was  iLt  its  origin  entiri'ly  of 
tbti  nature  vi  illi  apoplectic  ovary,  or  that  if  it  had  been  an 
ordinary  ovariiLo  cyst  it  coidd  have  undergone  epontaaieous 
resolution.  He  believed  that  tbe  hiatory  iudi>i'ated  that  the 
origiual  tumour  was  a.u  ovarian  or  broad  ligament  cyal  which 
ruptured  in  .Sbiit^^uibcr,  ami  ibat  tbe  cbaugta-  described  by  Mr. 
Uoran  aa  baviuf^'  eocurred  in  the  ovury  took  place  BubsL-qneutly 
to  tbat  date. 

Dr.  HoBROCRS  thought  that  the  term  apoplexy  was  good, 
although  flyiuo logically  indefensible.  But  its  meiining  should 
be  analogous  to  thiit  implied  when  used  for  other  reciona. 
Henw  it  ought  not  to  be  coHfiiied  to  those  tiaaes  in  which  the 
iurfuco  of  the  ovary  was  ruptured,  but  should  mean  hiBmor- 
rbage  into  a  U'riiafiau  follicle,  or  into  the  stroma  of  the  ovary 
vith  or  without  rupture  of  the  surface.  Mr.  Albii.a  Dorun  had 
drawn  attention  to  tbe  great  paiu  alt«ndiug  tbia  case,  and  had 
explained  it  by  the  distention  uf  the  organ.  This  was  probably 
correct,  but  Dr.  Honrocks  pointed  out  that  paio  in  the  ovarian 
region  did  not  nece»sarily  mean  ovaritis,  as  some  pbyAiciana 
seemed  Lo  tliiuk.  Indeed,  in  other  viseera  it  wms  generally  tbe 
capsule  that  was  affected  wbcu  paiu  was  a  prouiiaeut  aj  mptom, 
whilst  indamination  of  tbe  substance  of  tbe  organ  was  painless 
or  nearly  so.  He  mentioned  pleurisy  and  pneumonia,  uienin- 
citis  and  cercbritis,  perihei-atitis  and  hepatitis  ag  oiamplea, 
He  thought  tlmt  iipopleiy  of  the  ovary  was  not  bo  uncommon 
as  might  be  suppiosed  from  examinations  in  the  dead  body. 

Dr.  CoLLlMowonTn  was  sorry  that  the  t«rm  "hr&matoma" 
had  not  been  used  instead  of  "apoplexy."  The  former,  being 
alreadjT  employed  in  tbe  case  of  htemorrbages  into  the  connec* 


AFOPLBIX  Oir  THE  OTABT. 

live  tiasue  of  the  broad  ligament,  was  perfectly  ffimiliar,  and  opcii 
to  leaa  objection  ou  ruuiuj-  grounds.  He  did  not  think  thiLt  tin: 
aulhor's  exjilana-tiou  of  the  cliuical  jiheuoiueuu.  was  altugether 
convittcing.  The  sudden  diminution  in  size  of  so  huge  a  tumour 
eeemed  to  point  to  rui>tute  mtbor  than  to  gnidual  absorption 
within  tht>  tumour  itself.  That  no  sign  of  such  rupture  existed 
oith^r  ia  tho  walk  of  the  tumour  or  in  the  i>enU>nen.l  emvitj  did 
uot  disprove  it.  The  cxtravusuted  fluid  might  have  bceu  of  a 
simple  sero'Ua  nature,  such  as  would  easily  undergo  a.bsorption. 
Wir.il  repaid  to  the  cbauges  that  the  autlior  aJtuded  to  aa taking 
plucv  in  the  uv&ry  after  hasmorrbage  into  its  pariiucbytua,  he 
(.Dr.  Cull  ill  )pr  or  til)  hud  lat<rl7  met  vritli  such  im  iiistauce  as  hod 
heen  described  ia  the  case  of  a  youny  woman  of  twonty-threi?, 
upon  whom  abdominal  amotion  was  performed  m  December  last 
for  a  parovarian  cyst  of  tlie  right  side.  When,  in  the  ordinary 
routine,  the  appendages  of  the  other  side  came  to  be  examined, 
the  ovary  could  not  at  first  be  found.  It  was  evuntuaUy  die- 
covered  completely  wrapped  up  in,  and  adberuut  to,  omentum, 
a  portion  of  which  was  removed,  with  the  ovary  within  its  fo}ds. 
The  ovary  waa  represented  by  a  mere  shell  containing  dark 
brown  pidtaceous  material,  evidently  altered  blood.  It  bad 
uudergoue  uo  increase  in  size,  but  had  heeii  pulled  upwards  by 
the  omentum  some  diBt-anco  away  from  its  normal  position. 
The  Fallopian  tube  and  broad  ligament  on  that  aide  were  quite 
healthy, 

Mr.  DotUTT,  in  reply,  stated  that  ftmall  extravasations  of 
bbod  into  tho  foUiclea  and  substance  of  the  ovarie*  wero  pro- 
bably froquent.  The  big  ewetlingA,  full  of  blood,  not  rarely 
seen  on  the  surface  of  the  ovaries  of  healthy  young  Hulijecta  were 
often  normal,  the  healthy  ovary  and  ripe  follielea  being  much 
larger  than  was  geuerully  bi-licvcd.  As  mL-dical  men  first  studied 
the  ovary  in  the  dissecting-room,  where  specimens  of  that  or^un 
were  usually  atrophied,  thty  often  carried  false  ideas  of  tha 
ovary  tbroughout  their  careers.  Mr.  Doran  had  giveu  full 
reasons  why  the  original  swelling  could  hardly  have  been  a 
"  cyBtoiua  "  in  the  preeise  pathological  seuB»  of  the  word.  The 
dlaguoeis  made  by  I>r.  Amand  Kouth,  Mr.  F.  W,  Moriaon,  and 
Mr.  Thornton  was  clinically  quite  correct,  for  the  tumour,  a 
swollen  ovary  filled  with  blood,  certainly  formed  a  cyst.  The 
appearances  of  the  peritoneum  and  viscera  at  operation  proved 
that  no  ruptureof  the  ovary  or  of  any  cjut  or  blood-vessel  could 
have  recently  taken  place.  Extravaitation  of  fluid  into  the  sub. 
stance  of  the  ovarj',  inEauimatory  or  otherwise,  caused  great 
paiu,  UB  iu  orcbitis  and  iiitra-ocular  inttamiontion,  where  organs 
with  tough  cnpflules  were  involved,  Dr.  Cnllingworlh's  caaeof  a 
small  eyHliuH])Oplectic  ovary  found  adherent  nud  en tangli>d  in  the 
onientum,  high  above  the  pelvis,  reminded  Mr.  Doranof  aetmilar 
ca»e  described  in  his  paper  "  On  So-called  Non-ovariiui  Dermoid 


APOPLBXT  OP  THE  OTABT.  129 

Abdominal  Tumours  "  ('Med.-Chir.  Trans.,*  vol.  Ixxxviii,  1885). 
This  condition  was  akin  to  twisted  pedicle,  which  sometimes 
caused  hsemorrhage  into  OTEirian  cysts,  and  might  be  one  (cer- 
tainly not  the  sole)  cause  of  apoplexy  of  an  ovary  free  from 
cysts.  The  walls  of  the  ovary  exhibited  by  Mr.  Doran  con- 
sisted of  solid  ovarian  tissue  ;  they  bore  no  resemblance  to  the 
walls  of  a  true  cystoma  which  had  partly  collapsed.  "  Apo- 
plexy "  was  a  convenient  term.  Perhaps  "  hEBmorrhage  into  the 
ovary  "  was  better ;  "  hmmatoma  "  was  hardly  as  simple. 


APRIL  2nd,  1890. 

Alpkkd  L.  Gaij^bin,  M.D.,  Presideat,  in  tta  Chair. 

Proaent — 53  Fellowa  and  9  Visitora. 

Books  were  presented  by  Mr.  Alban  Doraii,  Dr.  GiUabiu, 
Dr.  Minot,  Mr.  J.  Kiiowsley  Thornton,  the  Amerioau 
AsBOciatiou  of  Obstetricians  and  Gyu:ecologists,  the  St. 
Tbonias's  HospitaL  Stuff,  the  publishers  of  the  '  Medical 
Annual/  and  La  Society  Obstetricale  et  GynScolo^ijne 
de  PariB. 

The  following  geotlemeii  were  elected  Follows  of  the 
Society  : — Augustus  W.  Addinsell,  M.Ii.,  C.M.Bdin. ; 
Goorgo  Edward  Anson,  M.A.,  M.D.Caiitab-;  George  Clack, 
M.B.,  B.S.Lond. ;  Albert  Ehrtuatin,  L.R.C.P.Loml. 
(South&m)  ;  Charles  Arthur  Morris,  M.A.,  M.B.,  B.C. 
Caulab.,  F.R.C.S.  ;  Frank  Frederick  Schacht,  B.A., 
M.H.Cantab.;  Hugh  Smith,  M.D.Loud. ;  and  Ernest 
Alfred  Suape,  L.B.C.P.Lond. 

The  following  gontlomen  were  proposed  tor  election : — 
Arthur  Henry  Robiaeon,  M.D.Durh.  j  and  Reginald 
Muzio  WilUamt),  M.D.Load. 


182 


LIVING  FEMALE    CHILD    WITH  THREE  LOWKR 

LIMBS. 

By  Clement  Godson,  M.D. 

Db.  Gomon  eliowed  a  feiudle  iiifmit  born  on  December 
SOtli,  ISSIJ,  iu  tbo  out-patieut  Laiiteruity  depurtmcut  of  St. 
Bartbolomow'a  Hospital.  Tbo  point  of  iutereet  ia  the  case 
was  that  sbo  possessed  a  tbird  log.  At  birtb  the  vertex 
presont(.id,  and  there  was  no  difficuUy  in  the  delivery.  The 
mother  had  borne  five  other  cbiidren.  The  third  wna 
an  idiot  and  bad  club-feet. 

Mr.  Albah  PoBAif  observed  that  some  ninlforuiutioQs  were 
evident  examples  of  dicbotouij.  whilst  in  olber  cases  where 
Kujiermiiiiemry  utriicliit'ea  were  n.pi>eudGd  to  an  otberwlsL'  well- 
formed  infftnt,  those  structures  repreaonted  an  acardiac  twin 
which  had  become  attittbed  to  its  brother.  Dr.  Qodnon's 
Bpecimen  was  clearly  due  lo  thu  former  condition  ;  whilst  to  the 
latter  (which  Mr.   Dorau  had  disf^ussed  at  length  in  a.  pa]ier 

Imbliehed  iu  the'  Transactions,"  1869,  p.  +)  wits  due  the  deformity 
mown  as  epigiiathus.  where  the  rudiments  of  a  ftetua  were 
attacfai^d  to  the  oral  cavity  of  an  otherwise  well-developed  child. 
IuU.-riu«diate  forms,  however,  existed,  wheru  ctaesitication  under 
either  of  tbi?  abovtt  kinds  of  malformatiou  was  not  bo  easy,  eape* 
cially  when  the  relations  of  the  eord  to  the  fiutus  and  Ita  appen- 
dagQ  could  not  be  ascertained. 


THREE  CASES  OP  CONGENITAL  DIAPHRAG- 
MATIC HERNIA  [TWO  BEING  ON  THE  RIGHT 
BIDE). 

By  Hebbbet  R.  SriKOBR,  M.D. 

Case  1, — A  male  child,  21  inches  long,  weighing  6  lbs. 
10  oz.  It  was  externally  quite  perfoct.  The  mouth,  buub, 
oretbrn,  and  penis  were  normiil ;  and  the  toeticlea  lay  in  the 
scrotum.    Through  a  hole  about  one  inch  in  diameter  at  the 


CONOENEIAL   UUPBSA.OHATICr   BESKIA. 


133 


for©-p&Tt  of  tho  rig^ht  side  of  the  diaphTagm  a  large  piece  of 
the  riglit  lolie  of  the  liver  had  passed,  and  behind  this  the 
email  intestiTie  Rud  the  ccecum  and  vermiform  appendix 
had  mUo  prolapsed.  The  piece  of  liver  had  asaamedj 
roughly,  the  shapij  of  the  pleural  cavity,  and  was  conetricted 
below  by  the  smooth  edge  of  the  hernial  ring.  Its  sur- 
face was  spotted  over  with  bmall  biackish-red  haamor- 
rhiiges,  resembling  Tardien's  spots  on  the  surface  of  the 
lengs.  The  ri^ht  luug  was  rudimentary  and  had  never 
filled  with  air.  The  heart,  thymus,  and  left  lung  were  on 
the  left  side  of  the  thorax,  pushed  over  by  the  displaced 
viscera.  The  left  luDgwasof  good  size  and  had  received 
air.  There  was  no  sac  to  the  hernia.  The  child  wns 
boro  natarally,  and  lived  for  three  quarters  of  an  hour. 

The  p[>st*tt]ortem  exaraiDation  showed  congestion  of  tho 
liver  and  of  the  meninges  of  the  brain,  butnohfemorrhage. 

Casr  2. — A  largo  full-term  etill-born  male  child.  The 
deformity  was  on  the  right  side,  as  in  the  precedinpcase. 
It  exactly  resembled  Case  1,  except  that  the  opening  in 
the  diaphragm  was  further  baek,  and  that  (iu  addition  to 
the  email  intestine,  ca'cum,  vermiform  appendix,  and  large 
pieoo  of  the  right  lobe  of  the  liver)  the  right  kidney 
had  also  passed  through  the  aperture.  There  was  no  sac 
to  the  hernia. 


Cabe  S. — A  Btill-born  female  child  20  inches  long, 
weighing  6J  lbs.  The  diaphragm  was  entirely  wanting 
OD  the  left  aide.  The  left  eide  of  the  chest  was  filled  by 
cnall  intestine,  the  stomach  and  great  omcntam,  the  epicen, 
Ik  piece  of  the  left  lobe  of  the  liver  of  the  aizo  of  the 
top  of  the  finger,  and  the  rudimentary  left  lung.  The 
CDsophagns  was  constricted  at  the  lower  end.  There  Tr« 
QO  sac  to  (he  hernia.  After  doalli,  exteiiaive  nipningeal 
haBmorrbage  was  found  over  the  upper  half  of  the  cortex 
of  both  corvbral  hemispheres- 


134 


CASK  OP  CENTRAL  CHOROIDO-RETINITIS  OCCUR- 
RING AFTER  LABOUR  AND  POST-PARTUM 
HEMORRHAGE. 


By  H.   MA0»AP9aT0H  JONIS,   M.D, 

Dtt.  Hackadquton  Jokes  showed  an  nplibhalmoBoopic 
drawing  (Bargoss)  of  "  central  choroido-retinal  "  disease. 
The  drawing  was  taken  on  March  4tli,  the  patient  having 
been  delivered,  with  very  severe  post-pnrtum  hfemorrhage, 
on  January  7th.  The  vision  of  the  left  eye  on  Febpimiy 
20th  was  found  to  be  reduced  to  counting  fiugei-s  at  five 
fe«t,  and  rea-ding  4-0  Snellen  at  three  foet.  The  defect  id 
vision  appeared  on  tlie  third  day  after  labour.  There  was 
DO  nlhuminniia  during  or  after  pregnancy.  Tliere  had 
"been  no  previous  visual  defect.  The  vision  of  the  right 
eye  was  normaS.  There  were  no  cardiac  complications. 
The  ophthalmoscopic  appearances  were  aa  follows.  A 
constellation  of  white  dots  was  scattered  over  tJie  area  of 
the  macula,  but  not  oUowhorc.  The  macula  itself  was 
somewhat  blurred  in  appoai-iitioo,  and  the  whole  uf  this 
region  was  marked  by  greyish-rod  pnnctatioaa,  whtoh 
were  also  scattered  hetween  it  and  a  somewhat  white 
papilla,  with  few  and  thin  vessels.  There  was  a  black 
crescentic  (physiological)  margin  of  choroid  at  the  nasal 
aide  of  the  papilla.  There  were  no  vessels  in  the  region 
of  the  mnculn.  Dr.  Macnanghton  Jones  drew  attention 
to  the  rare  occurrence  of  this  affection,  the  dietinguialiing 
features  between  it  and  the  retinal  cbaugos  in  Bright's 
disease,  its  occurrence  io  one  eye,  and  its  association  an 
this  case  with  labour  and  hromorrhngo.  The  Bimilarityof 
the  appearances  here  observed  to  those  described  by  Mr. 
Nettleship  in  "central  guttate  choroiditis  "  was  striking. 
The  case  was,  However,  more  exactly  allied  to  the  central 
choroido-Tetinitis  of  Mr.  Warren  Tay  and  Mr.  Hutchinson, 
the  latter  authority  surmising  that  these  "  dots  "  miglib 


EXTRi.-OTig&IKS  OBSTATIOtf.  135 

be  of  a  colloid  nataro.  Tho  Lsomorrhage  Jiftd  probably 
led  to  chopoida!  thrombosis  which  had  caused  the  imtn- 
tion,  leading  up  to  the  rctiuitiB  and  these  special  "dots." 


UTERUS  REMOVED  BY  PORKO'S  OPERATION. 

By  C.  J.  CotLINOWOBTH,  M.D. 

Dk.  Ciii.f.iNOWOKTH  exliilpitetl  the  ntems  from  a  case  of 
OaeBareJiii  section.  After  the  introduction  of  tltc  uterine 
suturffi,  persistent  ha3morrhage  from  a  divided  sinus  made 
it  necessary  to  remove  tlie  uterus  by  the  method  of  Prof. 
Porro.     Both  mother  and  child  were  saved. 


FCETUS    AND    PLACENTA    FKOM    A    CASE    OF 
EXTRA-UTERINE  GESTATION. 

By  C.  J.  CDHiNowoRin,  M.D. 

Dr.  CcLLiJiawoBTH  idso  showed  n  fally  developed  Ffctus 
and  placenta  removed  the  previons  day,  by  nbdorainal 
section,  from  a  case  of  extra-uterine  gestation.  The  sac, 
formed  by  the  right  broad  ligament,  was  stitched  to  the 
lower  pare  of  the  abdominal  incision.  Tlie  operation  was 
performed  exactly  four  weeks  after  the  cesaation  of  foetal 
movements.  The  removal  of  the  placenta  was  therefore 
commenced  cautiously,  but  was  accompliHhed  without 
serious  hsemorrbage. 


1S6 


CANCEROUS  UTEEI  REMOVED  BY  VAGINAL 
HYSTERECTOMY. 

By   C.  J.   CULLISQWORTH,   M.D. 

Dr.  Cullinqwokth  further  exhibited,  in  illiiBtration  of 
his  paper  read  tlio  same  evening,  four  cancerous  uteri 
removed  by  Yag^nal  bjsterectomyj  and  fiye  specimens  of 
Dancer  of  the  uterijs  from  St.  Thomas's  Hospital  Jltfaseam. 
Detailed  descriptions  of  the  former  were  given  in  tho 
pn.por  (p.  141),  and  of  the  latter  in  an  appendix  (p,  164). 


DISEASED    OVARIES    AND    TUBES. 
By  C.  H.  CAfi-rsB,  M.D. 


THREE    SPECIMENS    SHOWING    REMOVAL    OF 
CERVIX  UTEBI  FOR  MALIGNANT  DISEASE. 

By  Abthitb  H.  N,  Lewheb,  M.D, 

Dn.  LswBRa  showed  specimens  from  three  cases  of  eupra- 
vAginal  nmputntiou  of  the  cervix  for  malignant  disease. 
They  illnstrated  the  class  of  caspB  in  which  total  extirpa- 
tion of  the  uterus  offered  no  advantage  over  the  supra* 
Tagiiial  amputation. 

In  one,  a  specimen  of  crater-like  ulcer  (No.  4  in  the  series 
published  by  Dr.  Lewcre*),  the  patient  remained  well,  and 
free  from  recurrence  for  nearly  twelve  months  after  the 
operation.  Then  recurrence  took  placo  in  tho  pelvis  late- 
rally, at  some  distance  (about  one  and  a  half  iDches)  from  the 

"  '  Fnotical  TetUlxwIt  of  tlio  Dititiiti  <if  Women,'  jad  od.,  p.  426. 


cijicBA  or  qppbb  part  of  oibvix. 


137 


stump.  This,  and  the  part,  of  tlie  uterus  left  behind,  were 
quite  aaaffected  by  the  malignant  ^owth  to  tbe  last. 
Obviously,  in  this  L-ase  no  good  would  have  resulted  from 
total  extirpation.  In  the  eecond  specimen  (No.  12  in  the 
Beries)  there  was  a  cauliflower-growth,  the  size  of  half  a 
crowBj  the  patient  was  still  qnite  well  and  free  from  recnr- 
rence  at  the  present  time,  one  year  and  teu  mouths  since 
the  operation.  In  another,  the  third  specimen  (No.  10  in 
tbe  aeries],  where  there  was  a  largo  cauUHower-growth 
ohtefly  affecting  the  posterior  lip,  the  patient  was  three 
months  pregnant  at  the  time  of  operation.  Examination 
of  the  specimen  showed  that  there  wag  an  ample  width  of 
Wealthy  tisane  in  the  direction  of  the  uterus,  much  wider 
than  the  area  of  sound  tissue  laterally  and  towardn  the 
vagina.  This  patient  waa  atill  free  from  recurrence  ;  it 
was  now  nearly  eight  months  since  the  operation. 


CASE  OF  CANCER  OP  UPPER  PART  OF  CERVIX 
EXTENDING  INTO  BODY  OF  UTERUS,  WITH 
VERY  LITTLE  DISEASE  TO  BE  SEEN  OR  PELT 
BY  THE  VAGINA;  VAGINAL  HYSTEREC- 
TOMY;  RECOVBRYf  RECURRENCE  OP  DIS- 
EASE j  DEATH  THIRTEEN  MONTHS  AFTER- 
WABDS. 

B7  a.  E.  Hbumah,  m.b. 


E.  T— ,  aged  46,  admitted  September  lOth,  1887. 
Began  to  menstruate  when  aged  twelve,  alwaya  regular 
except  during  pregnancy ;  with  pain  ao  bad  as  to  lay  her 
up  each  month  until  child-bearing.  Was  married  at 
seventeen ;  had  twelve  children  and  four  miscarriage.'^, 
tbe  Last  six  years  ago.      No  illness  until  the  pi-Qseut. 

The  present  illness  dated  from  eight  and  a  half  montha 
ago.  Then  the  patient  felt  a  sense  of  weight  and  unoan- 
oees  ia  tbe  right  lower  abdomen.     A  month  later  a  yellow 

TOL.  zxzii.  10 


186 


CAHCEB    OS   UPPECK    PAUT    OV    CXSTIX. 


discharge  began,  and  it  continued  fiioce,  bnt  had  never  lieea 
oSflusire,  tliough  from  the  beginning  often  tinged  with 
blood.  There  was  hBeinorrhage  for  three  weeks  before 
adtnission ;  the  appetite  throaghout  was  good.  Bowels 
costive,  but  no  pain  on  defsecatioa.  Pain  not  severe. 
Patient  stated  that  she  had  not  got  thinner.  Weight  14  st. 
bi  lbs. 

On  admission  the  patient  was  florid  and  well  nonriahed. 
The  uterus  was  moveable.  The  vaginal  portion  was  healthy 
exoept  for  a  ring  of  excavating  ulceration  anrrounding  the 
oa  externum,  bleeding  when  touched. 

September  16th. — Patient  was  anieathetised,  with  a  view 
of  removing  the  cer?ix  uteri.  On  careful  examination 
some  induration  was  found  in  the  left  lateral  fornix.  The 
operation  for  removal  of  the  cervix  was  commenced  in  the 
usual  way.  In  cutting  into  the  upper  part  of  the  cervix 
in  order  to  separate  it  from  the  body,  it  wbb  found  that  the 
knife  went  into  a  ragged  cancerona  cavity,  which  extended 
up  into  the  lower  part  of  the  body  of  the  uterus.  The 
cervix  broke  down  so  readily  that  it  could  not  be  used  as  a 
means  of  drawing  down  the  body,  and  it  was  therefore 
separated.  The  body  of  the  uterus  was  then  removed. 
The  Woftd  ligaments  were  sacured  by  ligatures.  Iodoform 
was  freely  duated  on  the  parts,  and  an  iodoform  ganze  plug 
put  in  the  vagina. 

I'he  patient  made  a  good  recovery.  The  highest  tem- 
perature reached  was  101 '8°  on  the  evening  of  the  third 
day.  After  the  fourth  day  it  never  exceeded  100*,  and 
after  the  ninth  day  waa  noroial.  On  October  3rd,  weight 
13  St.  7  IbB. ;  January  13th,  1888,  weight  14  st.  5  lbs. 

The  patient  died  on  October  22nd,  1888,  from  recurrenoe 
of  the  dlaeaso;  bnt  as  she  waa  not  in  hospital  no  details 
of  the  lllnees,  or  autopsy,  could  bo  obtained. 

The  specimen  consiated  of  the  cervix  and  body  of  the 
atema.  The  vaginal  aspect  of  the  cervix  was  healthy  ex- 
cept that  it  was  thickened.  The  o»  extemnm  was  Iriangn* 
lar  in  shape,  and  not  larger  than  a  threepenny-bit,  and  it 
formed, aaseoa  from  the  vaginal  aspect,  an  excavation  filled 


»A01»AL   BYSTEBBOTOSt, 


189 


with  smftU  warty  growths.  TLo  part  of  the  cervix  tliat 
had  been  attached  to  the  body  of  the  uterus  formed  an 
irregular  cavity  lined  with  loose  warty  and  villous  growths. 
These  growths  extended  to  within  an  inch  of  the  fundus 
uteri.  In  the  cervix  only  a  very  small  band  of  healthy 
tiBsue  bounded  the  growth  peripheraHy.  The  body  of  the 
uterus  was  enlarged,  its  wall  being  nearly  an  inch  thick, 
bat  its  cavity  waa  not  dilated^  and  its  lining  membrane 
above  the  cancer  did  not  show  any  microscopical  changes. 
The  specimen  was  No.  2170  in  the  London  Hospital 
UQaeam. 


SARCOMATOUS  UTERUS  REMOVED  BY  VAGINAL 
HYSTERECTOMY. 

By  W.  R.  Dakin,  M.D. 

Db.  Dacih  showed  a  ntema  whioh  ho  had  rcmovod 
Beventeen  days  previouoly  from  a  patient  aged  51.  Sho 
watt  a  widow,  and  had  not  meustraated  for  six  yearti. 
Six  months  ago  she  began  to  have  slight  hsemorrbage 
from  the  vagina,  and  this  had  steadily  increased  till  it 
was  profase  and  very  frequent,  when  she  came  to  the 
hospital.      She  had  do  paiu  and  hardly  any  discharge. 

Oa  examiuattou  the  vagina  was  foand  perfectly  free 
from  growth,  and  the  vaginal  portion  atrophied.  The 
position  of  the  os  was  indicated  by  a  dimple,  and  the 
Hoger  just  entering  this  camo  on  a  brittle,  profusoly 
bleeding  surface.  The  length  of  the  whole  cavity  of  the 
uterus  was  two  and  a  half  inches.  The  body  was  there- 
fore somewhat  enlarged.  She  was  admitted  and  examined 
under  an  antesthetic.  The  uteni.<4  waa  drawn  down,  the 
cervix  curetted,  and  the  body  explored.  The  growth  was 
f<Mud  to  extend  up  towards  the  right  comu.  There  waa 
no  deposit  round  the  utenu,  uud  the  organ  was  very  freely 


VAQINAL    BTBTUBBiClOHT. 


moveable,  being  perbaps  sligbtly  held  wTien  it  was  at- 
tempted to  draw  tbe  fundus  far  to  tbe  left.  Dr.  Dakin 
then  decided  to  remove  the  whole  uterus.  All  her  other 
organs  were  found  iioruial.  She  was  douched  for  three 
days  before  operation  twice  a  day  with  a  1 — 2000  eolation 
of  sablimate,  the  vaginal  walla  being  rubbed  with  the 
solution. 

The  operation  presented  no  difficulty ;  the  bladder  "was 
first  separated  up  to  the  utero-vesical  fold  of  peritoneum, 
then  Douglas's  pouch  opened  and  the  broad  ligaments  tied 
in  sections,  the  uterus  being  slightly  pulled  down.  Three 
ligatures  were  put  on  the  right  side  and  four  on  the  left. 
There  were  no  adhesions,  and  the  surrounding  tissues  were, 
as  far  as  could  be  judged,  normal.  This  took  fifty  minutes, 
but  after  it  was  all  done  and  the  patient  was  just  going 
to  be  remoTed,  she  began  to  bleed  profuaely,  the  blood 
ooming  fi'om  somewhere  high  up  in  the  left  bread  liga- 
ment. Sometime  was  spent  in  loolciug  for  the  vessel,  but 
as  it  could  not  be  found,  and  the  patient  was  losing  con- 
siderably, the  pelvis  was  plugged  with  several  yards  of 
iodoformed  carbolic  gauze.  This  was  removed  in  forty- 
eight  hours  and  was  theu  (juite  sweet.  No  further  bleeding 
occurred,  She  r&llied  well,  and  the  temperature  did  not 
rise  to  100"  until  the  fifth  day,  when  it  was  brought  down 
by  an  enema.  The  ligatures  which  had  been  left  long  were 
out  to  about  throe  incfaea  on  the  third  day,  and  c&mo  away 
one  by  one.  She  needed  no  etimulant  or  special  treat- 
ment, and  was  at  the  present  time  convalescent. 

The  growth  was  found  on  mioroecopical  examiQation  to 
be  a  spindle-celled  sarcoma,  commencing  probably  in  the 
eonneotive  tissue  of  the  cervix. 


141 


FOUR  CASES  OF  VAGINAL  HYSTEBEOTOMY. 

By  C.  J.  CcLLiNQWORTH,  M.D.,  F.R.C.P., 

OB8TtTBtO  PHYfllCUM'  TO,  AHS  XKCTVnBa  OM  OBniTXIC  UIMOIKX  AT, 
IT.  TBOMAfl'S  BOaPtTAI:. 


(Received  Marcli  lit,  ISM.) 
{Abstract.) 

Four  cuscb  of  botu.1  t-xtirpatiou  oi  llic  uh*rui  per  vaginam  Arc 
related,  two  of  coIuniaar-v^'Ued  varciuuina  of  the  cervix,  and 
two  of  sqiiAEiiDUS'CeUed  carcinomti  of  the  porlio  va^itiAlis.  In 
three  of  the  oases  the  jtatients  rocoYcred  fitun  the  operation ; 
one  showed  recurrence  in  eight  mouths.  ITie  disease  had  ex- 
tended into  the  bod;  of  the  uterus  in  both  the  caioa  of  cerTical 
carvinoinu.  and  the  author  eipreases  a  doubt  wL4<th«r  t\ut  tta- 
Bues  above  the  iutenial  os  are  respected  as  frequeutl;  )ut  is 
Museum  specimonfi  arc  ebowQ  where  the  corpus  uteri 
baa  beeu  more  or  less  invaded. 

In  the  fatal  case  the  patient  had  u  parOTarian  cjBt,  situated 
beliiud  the  uterus;  this  was  removed  hy  abdominal  Koctiou  ou 
the  same  dajr  that  the  ragbal  hyaterL-ctoiuy  nau  performed. 
Death  occurred  ou  the  third  day,  apparently  from  iutestiool 
paralysis  ■ 

The  paper  ooncludeB  witli  some  reinarks  on  the  diminiuhed 
mortality  of  the  opeiatiun  as  compared  with  what  it  was  when 
Dr.  W.  Duaeau's  paper  was  read  in  1885. 

Cask  1. — Mary  K — ,  aged  46,  waa  admittod  iuto  St. 
ThoniaB'8  Hoepital  Jaimaiy  7t]i,  1889,  ou  accouut  of 
im^lar  uterine  hfemorrbage,  which  had  tieen  guing  on 
since  October,  1888,  aceom|»iDied  with  loas  of  Beah  and 
pajn  in  the  left  iliao  region  and  over  the  sacrum. 


142 


VAOIN&L    HTSTDKECTOHr. 


Tfae  pationt  was  married  &t  tlie  age  of  twenty-one,  and 
baa  had  thirteen  children  at  term  and  five  premature 
births,  one  at  three  months  and  a  half,  the  others  at  from 
fonr  to  five  months.  The  last  cliikl  was  horn  in  October, 
1886.  On  that  occasion  the  patient  bad  post^partum 
hjemorrhage*  For  the  last  four  years  menBtraation  has 
been  profuse-  There  baa  been  uo  purulent  or  offensive 
discharge.  The  blood  lost  during  the  past  three  months 
baa  been  of  varying  quantity  and  of  a  bright  red  colour, 
the  discharge  never  ceasing  entirely. 

The  nterns  was  normally  anteflexeJ  and  freely 
inoTeable.  Body  slightly  enlarged  ;  cervix  niiich  enlarged 
and  indurated ;  os  fissured.  Length  of  uterine  canal 
three  inches.  No  thickening  of  broad  ligaments  de- 
tected. 

On  February  5th,  the  haemorrhage  having  continued 
more  or  less  in  spite  of  the  rest,  the  patient  was  carefully 
oxamined  under  etiier.  On  the  posterior  tip  of  tbo 
oervii  a  BUBpicious-looking,  irregular,  dusky-red  patch  was 
seen,  raised  slightly  above  the  eurrouudiug  enrface.  It 
was  about  an  inch  in  its  longer  diameter  and  half  an  inch 
in  its  shorter^  and  extended  up  into  the  cervical  canal. 
There  whb  a  similar  but  smaller  patch  on  the  anterior  lip. 
The  diseased  surfaces  bled  on  the  slightest  touch.  The 
cervix  generally  was  indurated.  A  omati  portion  of  the 
diseased  posterior  Up  was  removed  for  microscopical 
exam  i  nation. 

On  February  Ttb,  Mr.  Sbattock  reported  that  the 
epecimen  proved,  under  the  microscope,  to  be  typical 
glandular  carcinoma. 

The  question  of  removal  of  the  entire  uterus  was  there- 
fore considered  and  fully  explained  to  the  patient.  The 
patient  herself  was  willing  to  have  the  operation  performed, 
but  as  her  husband  would  not  give  bis  consent,  she  left 
the  hnspital  on  February  16tb. 

On  March  4th  she  was  readmitted  for  operation,  her 
husband  having  now  consented  that  it  should  be  done. 

The  operation  of  total  extirpaCiou  through  the  vagina 


TAOIHAL   HTSTBKKCTOMT. 


143 


was  accordingly  performed  on  March  8tb,  ether  bein^ 
adminiBtered  by  Mr.  White.  The  Taginul  orifice  was 
large,  the  vaginn  itself  roomy,  and  ita  walU  lax.  The 
uterus  was  normally  anteflesed  and  freely  moveable,  but 
the  projection  of  the  cervix  into  the  vagina  was  esceed- 
ingly  slight,  not  exceeding  a  fraction  of  an  inch.  The 
anterior  lip  was  seized  and  drawn  down,  and  the  mncoaB 
membmae  in  front  divided.  This  was  qo  eooner  done 
than  the  tisanes  of  the  cervix  gave  way  and  the  volsella 
lost  itB  hold.  The  Beparation  of  the  bladder  was  aceom- 
pKshed  with  a  good  deal  of  difl3culty.  The  posterior  in- 
cision was  then  made  just  above  the  posterior  lip,  and, 
two  fingers  being  placed  meantime  in  the  rectum,  the 
uterus  was  separated  by  the  Bnger  from  its  poaterior 
attacbmeDts.  The  peritonenm  came  into  view  and  was 
incised  with  the  point  of  a  scalpel,  the  opening  being 
afterwards  eolarged  by  means  of  the  fingers.  The  ante* 
rior  and  posterior  incisions  were  now  connected  by  lateral 
iociaioDs  through  the  mucous  membrane  of  the  vagina,  and 
the  vesico- uterine  fold  of  peritoneum  was  divided.  (An 
attempt  to  pass  two  fingers,  from  beliind,  over  the  fundus, 
to  serve  as  a  guide  in  dividing  the  peritoneum  in  frouC, 
was  frustrated  by  the  fingers  becoming  entangled  in  a 
ma»e  of  loose  tissue.  This  afterwards  proved  to  be 
omentuui  adherent  to  the  fundus  uteri.)  The  bladder 
was  DOW  once  more  carefully  explored  with  the  bladdur- 
iOund  and  found  to  be  uninjored.  The  base  of  the  broad 
ligament  on  each  side  was  then  exposed  by  digSit^cting  off 
the  vaginal  mucous  membrane,  and  a  stout  silk  ligature 
was  passed  completely  through  the  upper  part  of  the 
oervix,  from  before  backwards,  in  the  middle  line,  to 
enable  the  uterus  to  he  drawn  down.  Passing  a  finger 
behind  the  ba.'^e  of  the  left  broad  ligoment  and  the  thumb 
iu  front  of  it,  an  aneurysm  needle  was  passed  through  the 
lower  part  of  the  broad  ligament,  at  a  short  distance  from 
the  side  of  the  uterus,  and  threaded  with  a  double  silk 
ligature.  The  ligature  was  divided  so  that  two  ligatures 
passed  through  the  same  opening.     Half  a  knot  was  made 


VAGIHAL    HYKTEhEOrOUr. 


on  one  and  tlie  enda  held  tiglit,  vhile  a  fnll  knot  was  tied 
OD  the  other.  Tlie  fir&t  knot  wqb  then  completed,  and 
the  utei'QB  separated  with  scissors  from  its  lateral  con> 
nections  and  divided  np  to  the  level  of  the  ligatare. 
8imilar  ligatures  were  applied  to  the  middle  section,  and 
fiuBilly  the  upper  border  of  tLe  broad  ligament  was 
hooked  down  by  the  finger,  bUd  the  nppermost  cectiou  of 
the  broad  ligameot,  inclnding  the  Fallopian  tube,  was 
ligatured.  By  dividing  the  tisBues  as  close  to  the  uterus 
SB  poBsible,  with  scisaors,  th«  uterus  was  set  entirely 
free  on  that  side.  No  hsemorrhage  took  place  from  the 
broad  ligameut.  The  body  of  the  nterus  was  now  seized 
and  pulled  down  sideways  so  as  to  enable  the  right  broad 
ligament  to  be  brought  into  view  and  tied  from  above 
downwards.  A  band  of  the  great  omentum,  adherent  to 
the  fundus  uteri,  was  tied  and  divided,  and  the  omentum 
pushed  up  into  the  abdomen.  When  this  had  been  done 
and  the  right  broad  ligament  divided,  the  uterus  was  frco 
and  was  removed.  The  tubes  and  ovaries  wore  examined, 
found  healthy,  and  left.  The  omentum  now  prolapsed. 
Again  and  agaiu,  after  being  pushed  up,  it  came  down. 
It  was  therefore  held  up  while  the  vagina  was  packed 
with  two  long  strips  of  iodoform  gauze,  the  packing 
reaching  for  a  little  distance  within  the  peritoneal  cavity. 
The  ligatures  on  the  broad  ligament  were  left  long,  a  piece 
of  india-rubber  tubing  being  elipped  over  each  bundle 
outside  the  rulvs.  No  attempt  was  made  to  bring  to- 
gether the  edges  of  either  the  vaginal  or  peritoneal  wound. 
Verj"  little  blood  was  lost  during  the  operation,  which 
lasted  two  hoars  and  a  quarter.  Pads  of  wool,  squeezed 
out  of  a  solution  of  corrosive  sublimate,  I  in  1000,  were 
nsed  instead  of  sponges.  No  douching  was  employed 
either  during  or  after  the  operation.  A  wood-wool  pad 
was  applied  externally.  There  were  no  symptoms  of 
shook  during  the  operation. 

For  the  first  day  or  two  the  patient  was  sick  at  intervals, 
and  in  spite  of  a  small  dose  of  morphia  subcutaneously 
she  slept  badly  the  night  after  the  opcraliou.      The  cathc- 


VAOINAL  EySlEBEOTOHY. 


145 


tor  was  pBBBed  every  six  houTB.  Temperstiireon  the  9th, 
98-8°  to  100-8° ;  on  the  lOth,  996^  to  101°. 

The  iodoform  gauze  was  removed  for  the  Grat  titae 
on  the  niorniDg  of  the  11th,  eixtj-six  hoara  after  the 
operfttion  ;  it  was  eatumted  with  blood  und  blood-stained 
serom,  but  qaito  free  from  disagreeable  odour. 

It  was  replaced  b;  a  eiagle  strip,  wKicli  was  not  carried 
beyond  the  Taginal  wound,  but  simply  packed  loosely  in 
the  vagina,  The  india-rubber  sheaths  were  removed 
from  the  ligaturoa,  which  were  now  simply  tied  in  two 
bundles.  It  was  thought  the  india-rubber  tubing  might 
harbour  dischargee  and  interfere  with  the  drainage-action 
of  the  ligatures.  The  change  of  dresBing  was  followed 
by  an  attack  of  vomiting,  and  by  acnte  pain,  which  passed 
off,  however,  in  the  courae  of  an  hour  or  two.  Later  in 
the  day  the  patient  paaaod  urine  voluntarily  for  the  first 
time  since  the  operation.  Temperature  oa  the  11th  varied 
from  99"  to  102°. 

Next  day  (March  12th)  the  patient  was  very  comfort- 
able and  quito  free  from  pain.  Temp.  99°  to  lOO'*.  No 
sickness. 

15th. — Discharge  purulent  and  offensive.  Gauze 
tampon  diBcontinuod.  Bowels  have  acted  slightly.  No 
pain.  Not  much  desire  for  food.  Ordered  a  fowl  for 
dinner. 


profuse    and     blood-stained. 
Tempoiature,   13tli  to    17th, 


17th. — Discbarge  more 
Patient  quite  comfortable, 
varied  from  98-4"  to  lOO'-t". 

21&t  (fourteenth  day  from  operation). — All  the  liga- 
tures on  the  left  side,  and  all  except  two  on  the  right,  boing 
loose,  were  removed;  a  small  portion  of  sloughing  tieene 
came  away  with  the  ligatures  on  tho  left  side.  The 
removal  was  nearly  painless.  Patient  complains  of  a 
pricking  pain  during  mioturition,  but  is  otherwise  very 
comfortable. 

24th. — The  two  remaining  ligatures  have  not  yet  become 
loose ;  traction  on  them  causes  coneidei-able  pain,  Tho 
central  part  of  tho  Taginal   wound  has  united;  at  each 


146 


VAQINAL    HY8TEBE0TOMT. 


angle  there  is  a  small  apertnrej  not  large  enough  to 
admit  the  tip  of  the  finger.  Temperature,  18th  to  24th, 
98-2°  to  99-8°. 

From  this  date  tie  temperature  was  normal.  The 
patient  left  her  bed  on  the  SOth,  and  on  April  15th  she 
was  sent  to  the  ConvuloBCont  Home  at  Eastboome.  One 
of  the  remaiaing  ligatures  was  atill  firml;  held,  the  other 
bad  come  away  on  April  9tb. 

She  presented  herself  at  the  hospital  od  her  return  from 
Eastbourne,  looking  very  well.  The  opening  at  the  loft 
angle  of  the  wound  had  not  yet  become  entirely  closed, 
and  there  was  a  little  purulent  discharge  quite  free  from 
odour. 

For  811  months  after  the  operation  the  patient  gained 
flesh ;  after  that  she  began  to  lose  ground. 

At  the  beginning  of  November  (eight  months  after  the 
operation)  there  was  noticed  for  the  first  time  a  small 
bud  of  Boft  growth  at  the  left  angle  of  the  wound,  which 
bad  never  entirely  healed.  Ther«  had  been  no  hsemor- 
rhage- 

On  December  I4th  the  growth  had  increased  to  tho  size 
of  a  hazel-nut,  and  patient  complained  of  a  little  pain  ou 
the  left  aide  of  the  peMa  aind  some  irritability  of  bladder. 
The  discharge  had  been  slightly  blood-stained  for  the 
past  three  days. 

February  8th,  1890. — Growth  not  perceptibly  increased 
in  fliKO.  No  heemorrhage  since  last  note.  Very  slight 
watery  discharge,  without  ill  odour.  Frequency  of  mictu- 
rition continues,  and  there  is  pain  before  and  after  reliev- 
ing the  bladder.  There  is  continuous  pain  deep  in  the 
pelvis  on  the  left  side. 

The  litems  was  handed  over  to  Mr.  Shattoek  immedi- 
ately after  its  removal.  A  large  portion  of  the  cervix 
had,  owing  to  its  friability,  been  broken  away  during  the 
operation,  so  that  the  apeciuien  consisted  of  the  body  and 
adjoining  portion  of  the  cervix.  It  was  at  once  placed  in 
hardening  fluid,  with  a  view  to  careful  microscopical 
examination.     The  following  is  Mr.  Shattock'e  report : — 


VAOINAt    HY8TEKECT0MT. 


147 


"  The  specimen  shows  that  the  morbici  growth  extenils 
one  centimetre  (f  in.)  into  the  siibtitance  of  the  posterior 
w&U  of  the  uterus,  above  the  level  of  the  iatemal  ob.  The 
lower  sarfaoe  of  the  parts  remoTed  is  exceedingly  irregu- 
lar, owing  to  the  bre&ting  Bwny  of  the  greater  part  of  the 
diseased  cervix  at  the  operation.  In  front,  the  growth 
infiltrates  the  entire  thioknesa  of  muscnlar  tissue,  but  the 
peritoueam  is  eeparable  and  aninvotved.  The  same  ia 
true  of  the  posterior  wall.  Tlie  section  made  at  the  opera- 
tion through  Hie  broad  ligament  shows  no  extension  of 
the  growth  in  the  divided  surface.  The  connective  tissae 
at  the  aide  of  the  cervix  huB,  however,  undergone  infiltra- 
tion. 

"  The  length  of  the  cavity  of  the  corpne  uteri  ia  an  incli 
and  a  half. 

"  Hintolf>gy,-~-Hectlon  shows  branching  colomns  of  ppi- 
tbeliam  invading  the  muscalar  tiRsme.  The  colniuus  have 
no  lumen,  and  are  composed  of  closely  packed  cells,  having 
oval  nuclei  arraogcd  vertically  to  the  sabjacent  surface 
(columnar-celled  carcinoma)." 

I  defer  my  remarks  on  this  case  until  the  latter  part  of 
the  paper. 


Caii  2. — Emma  F — ,  aged  35,  married,  was  admitted 
into  St.  Thomas's  Hospital  April  23rd,  1889,  suffering  from 
a  cystic  tumour  of  the  right  broad  ligament  and  ulcerating 
oajvinoma  of  the  vaginal  portion  of  the  cervix  uteri. 

The  patient  had  been  married  thirteen  years,  and  had 
not  been  pregnant.  Always  had  good  health  and  men- 
struated regularly  until  sixteen  weeks  before  HdmisKiun, 
when  a  hiemorrhage  commenced  which  had  contiuned  ever 
since.  For  the  last  month  there  had  beeuan  offensive  dis> 
charge,  loss  of  appetite,  and  some  loss  of  flesh. 

Patient  was  a,  strongly  huilt,  hottlthy-looking  woman. 

The  anterior  lip  of  the  cervix  uteri  preeented  an  uneven, 
graonlar,  easily  bleeding  and  flattened-ont  surface  of  ulce- 
ration, with  hard,  everted  edges.  Behind  the  posterior  Up 
there  was  a  deep  groove  of  ulceration  running  from  gide 


TAQIMAl    HTSreBRCTOUY. 


to  side,  dividing  it,  as  it  were,  into  two  irregaJar  flaps- 
Tbe  Qteras  was  freely  moveable,  and  no  infiltration  could 
be  detected  around  it.  The  disease  had  not  extended  on 
to  the  vaginal  wall  anteriorly  and  not  farther  than  the 
vaginal  reflection  posteriorly.  Behind  the  uteros,  and 
springing  from  the  right  side,  was  a  amooth  cystic  tumour, 
occopying  the  liollow  of  the  ssicram. 

The  organs  of  the  chest  were  healthy.  The  urine  con- 
tained albumen  [about  -jV)  J  ^P-  gr.  1014. 

On  April  25tL  &bdomiDal  section  was  performed,  and  a 
cyst  of  the  broad  ligament,  measuring  5  in.  by  o^  in.,  wae 
removed  unopened,  after  tying  the  pedicle  with  a  single 
ligature.  The  con  tents  were  clear  serum.  The  right 
ovary  lay  close  to  the  tumour,  and  the  right  tube,  much 
elongated,  ran  along  its  wall,  the  fimbriated  end  being 
free.  The  wound  was  closed  and  dressed,  the  operation 
lasting  haliF  an  hour. 

The  patient  was  then  placed  in  the  lithotomy  poaition, 
and  the  whole  cervis  being  seized  with  a  volsella,  the 
entire  uterus  was  removed  per  vaginaw,,  the  steps  of  the 
operation  being  the  same  as  in  the  preceding  case.  Very 
little  blood  was  lost.  No  sutures  were  inserted  either  in 
the  peritoneum  or  vagina.  The  ends  of  the  ligatures  were 
left  long,  and  the  vagina  was  tamponed  with  iodoform 
gauze.  A  gauze  bag  of  sublimate  wood-wool  was  placed 
over  the  vulva.  The  operation  occupied  exactly  an  hour 
and  a  half. 

The  temporary  dressiog  of  the  abdominal  wound  was 
now  removed  and  the  usual  dressings  applied,  namely  a 
bug  of  wood-wool  next  to  the  wound,  and  over  this  a  large 
thick  layer  of  cotton-wool,  the  whole  being  secured  by  a 
many-tailed  flannel  bandage. 

The  patient  passed  a  fair  night.  At  6  B.m.  next  day 
she  vomited  for  the  first  time.  In  the  afternoon  she  com- 
plained of  a  patu  in  the  right  hypochondriac  region,  and 
her  countenance  assumed  an  anxious  expression.  The 
pulse  became  rapid  and  respiration  hurried;  the  abdomen 
became  somewhtit   dintcndcd,  and   vomiting  supervened; 


VAQIllAL    HYSTEGECTOHX. 


149 


On  cxftmiiLiTi.g  tho  cheat,  the  only  abnormal  sound.  det«cted 
was  a  double  bruib  intei-ual  bo  and  on  a  level  with  the 
nipple.  It  was  doubtful  wliether  this  was  exocaidLal  or 
endocardial. 

27ih. — Waa  sick  at  intervals  through  the  night  and  at 
5j  and  was  much  collapsed.  At  morning  risit,  patient 
looked  a  little  better.  The  abdomen  was  slightly  dis* 
tooded.  The  mouth  was  dry  and  thiret  was  complained 
of.  The  discharge  from  the  vagina  since  the  operatioii 
had  been  chiefly  Berum— ronly  slightly  blood-stained.  The 
tampon  was  easily  remored  this  morning,  and  no  further 
internal  dressing  was  applied. 

In  the  afternoon  the  patient  vomited  about  12  Said  ounces 
of  black  fluid.  The  abdomen  became  more  distended  and 
the  pulse  more  rapid  and  feeble. 

Being  unable  to  account  for  my  patient's  alarming  con- 
dition, and  revolving  in  my  mind  every  possible  cause,  it 
suddenly  occurred  to  me  that  I  had  omitted  to  ask  for  tho 
opongoa  to  bo  counted  before  clo&ing  the  abdominal  wound. 
The  nurse,  on  being  appealed  to,  assured  me  that  the 
number  was  correct,  but,  in  order  to  set  the  matter  at  rest, 
my  excellent  resident  officer,  Mr.  B.  C  Stabbj  had  the  stock 
of  sponges  counted.  One  of  tho  number  was  found  to  ho 
missing.  Immediately  on  being  informed  of  this  I  pro- 
oooded  to  reopen  the  abdomen.  With  some  difficulty 
tho  missing  sponge  was  discovered,  completely  enveloped 
in  omentum.  The  sponge  had  no  ill  odour,  and  there  wore 
QO  signs  of  peritonitis  beyond  that  usually  found  in  the 
immediate  neighbourhood  of  the  wound.  The  patient 
Beomod  no  worse  for  the  manipulations,  bat  the  vomiting 
and  distension  continued,  and  she  died  at  5  a.m.  on  the 
28th,  sixty-one  hours  after  the  operation. 

The  following  is  the  record  of  the  temperature,  &c. 


Temp. 

Pnlw. 

VLetp. 

l!6th,  6  p.iii. 

.1 1 

86-4* 

US 

... 

34 

8  II.RI. 

... 

100-4 

116 

... 

28 

Mdn. 

... 

09-4 

lis 

... 

26 

26tli.  i  •.m. 

-' . 

d6-2 

114 

..« 

t* 

IftO 


TiuOIHAl   BfSTKUBCTOHT. 


Temp. 

?iil» 

tt-p. 

S  a.m. 

9S-8 

104 

21 

Noon 

100-0 

116 

£4 

'Sp.ai. 

100-4 

134 

30 

S  p.m. 

100-9 

1S4 

30 

Uda. 

99-0 

134 

as 

27th,  8.80  n.ni. 

SOfl 

140 

40 

&  ■.m. 

100-a 

160 

40 

Sa.iii> 

100-8 

ItJO 

32 

Nooii 

100-tt 

160 

m 

■l  p.m. 

lOD-8 

170 

40 

d  p.m. 

100-0 

180 

42 

Autopsy  (at  2  p.m.  on  th&  29th). — On  opening  the  abdo- 
men there  was  seen  to  he  great  distenaion  of  the  stomach 
and  of  the  whole  intestinal  tract  from  duodennm  to  rectam. 
The  liver  was  pnshed  up.  There  wag  no  peritonltia,  ex- 
cept as  ehown  by  adhesioua  in  the  neighbourhood  of  the 
wound  in  the  abdomina!  wall  and  of  the  omentum  to  it- 
aelf.  There  was  no  twist  or  kink,  or  other  apparent 
mechanical  obstruction  of  the  bowel.  The  wound  in  the 
vaginal  roof  waa  closed,  so  that  no  coromumcation  exieted 
between  the  vaginal  citQal  and  the  peritonea,!  cavity,  except 
through  the  ligatures,  which  were  surrounded  by  adhe- 
sions at  their  attachments  to  the  broad  ligament.  There 
was  a  very  little  blood-ataiued  Quid  in  the  pelvia.  There 
waa  no  sign  of  hiumorrhaga  beyond  a  little  infiltration  of 
the  connective  tisaue  in  the  stump  of  the  uppermost  sec 
tion  of  the  left  broad  lignmeat.  The  bladder  and  nretera 
were  carefully  examined  and  found  uninjured.  A  large 
and  hard  lymphatic  gland  was  found  beneath  the  perito* 
neum,  on  the  lateral  wall  of  the  pelvis  on  each  aide,  imme- 
diately below  the  pelvic  brim.  The  left  ovary  and  Fallo- 
pian tube  Were  normal,  ■" 

The  lungB  were  compressed  and  congested,  1}at  other- 
wise healthy.  The  heart  was  normal,  except  for  a  patch 
of  the  sine  of  a  shilling,  of  recent  lymph,  on  the  anterior 
aspect  of  the  visceral  pericardium,  and  some  staining  of 
the  endocardium  of  the  left  ventricle.  There  were  patches 
of  atheroma  on  the  aorta. 

The  other  organs  were  healthy. 


VAOIHAL    BTBTEKECTOUT, 


151 


Bffport  on  the  Specimen. — Mr.  Shattook  received  tlie 
uterus  immediately  after  its  removal,  and  haa  kindly  far- 
nished  me  with  the  following  repoTt  of  the  result  of  his 
examination  :^"  The  portio  vaginalis  is  roughened  on  its 
onter  aspect  from  the  euperficial  ulceratiou  of  a  csrciao- 
matons  growth,  shown  by  tlie  microscope  to  be  of  the 
aqaamoaB-celled  vai-iety.  The  aatorior  lip  is  oonsiderably 
enlarged  liy  the  liiseaee,  which  has  infiltrated  also  the  ad- 
joining portion  of  the  vagina.  On  the  poaterior  aspect 
the  vaginal  portion  of  the  growth  is  deeply  ulcerated,  the 
edges  of  the  ulcer  l^eing  in&ltratod  and  thickened.  Ths 
disease  does  cot  involve  the  body  of  the  aterus.  In  the 
section  of  the  anterior  wall  of  the  cervix  the  new  growth 
nowhere  extends  upwards  for  more  than  half  an  inch. 
The  divided  edge  of  the  vagina  and  the  peritoneum  on  the 
posterior  surface  are  uninrolved. 

*'  Length  of  the  entire  uterine  cavity  two  and  a  hall 
inohee. 

"Histology. — In  vertical  eectioa  it  ia  shown  that  there 
are  braoohing  columas  of  Sat-celled  epithelium  invading 
the  muscular  tissue,  accompanied  with  abundant  amatl- 
celled  infiltration.  The  ulcerated  surface  is  formed  by  the 
breaking-down  of  the  growth.  There  are  many  leuco- 
cytes amongfit  the  epiihelial  cells  of  the  ingrowin^f 
oolQmDS.*' 

Hemarkt. — In  this  case  it  seems  necessary  to  explain 
why  the  two  operations  of  removal  of  the  parovarian  cyst 
and  removal  of  the  uterus  were  aodertakon  on  the  same 
day.  The  reason  was  this:  the  position  of  the  cyatio 
tumour  behind  the  uterus  made  it  desirable  that  it  should 
be  removed  before  undertaking  the  operation  oa  the  uterus.. 
To  have  performed  abdominal  section  and  allowed  the 
patient  to  recover  before  dealing  with  the  uterine  canoer 
would  have  involved  a  delay  of  at  least  two  or  three  weeks. 
There  boiug  already  ulceration  of  the  diseased  partx,  such 
a  delay  seemed  exceedingly  undeKirable.  Hence,  as  the 
oystio  tumour  appeared  to  be  of  a  simple  character  and 
non-adherent,  and  as  the  operation  for  its  removal  was. 


153 


.TAQIMAL  HTSTIBBaTOKT. 


tliereforo,  likely  to  be  capable  of  being  performed  rapidly^ 
I  decided  to  do  both  operations  at  once.  Tbe  first  opera- 
tion occupied  only  half  an  hour,  the  geoond  an  hour  and  a 
half.  The  nterua  was  very  moveable  and  easily  pullod 
down,  and  the  operation  was  accomplished  without  diffi- 
culty. The  operation  of  complete  extirpation  was  chosen 
in  preference  to  partial  removal,  becanae  I  had  no  means 
of  knowing  how  high  the  disease  extended.  The  speci- 
men shows  that  the  case  was  one  for  which  the  minor 
operation  would  probably  have  been  aafficient.  It  is  easy 
■to  be  wise  after  the  event. 

The  canae  oE  death  appeared  to  be  intestinal  pai-alyaisj 
ft  condition  after  abdominal  section  to  which  Mr.  Malcolm 
hai  specially  directed  attention.*  The  autopsy  showed  that 
there  was  no  mechanical  obstruction.  I  regret  that  I  did 
not  pass  the  rectal  tube,  which  might  have  had  the  effect 
of  relieving  the  distension.  The  lymphatic  glands  in  the 
pelvis  were  already  infected,  so  that  under  any  circnm* 
Btances  the  patient  would  have  had  a  recurrence.  I  am 
disposed  to  doubt  whether  it  is  ever  wise  to  operate  when 
tbe  nlcerative  procesa  has  commenced.  In  this  ca.sQ  I  was 
tempted,  by  the  excellent  state  of  the  patient's  health  and 
the  shorcneee  of  the  period  since  tho  iirat  symptoms  of  tbe 
di5ea«o  made  their  appearance,  to  give  her  snch  chance  of 
relief  as  operation  would  afford. 

Of  the  sponge  episode  I  am  heartily  ashamed.  The 
blame  rests  with  myself,  and  it  ia  no  palliation  of  tbe 
oversight  to  say  that  It  is  the  first  time  such  an  accident 
Las  occurred  to  me,  or  that  I  ainned  in  good  corapany.t 
I  see  DO  reason,  however,  to  think  that  the  sponge  did 
any  barm,  or  in  B.Dy  way  contributed  to  bring  about  the 
fatal  resnlt. 

Ca8B  3.— Amy  8—,  aged  43,  married,  was  admitted 
into  St.  Thomas's  Hospital  January  Ilth,  1890.      Married 

"  "Tho  CoDdition  And  Managvment  of  Che  ItiMtJnc  kfter  Abdouina) 
SoctioB,"  '  Jlcd.-Chir.  'Xniu.,'  vol.  Ixxi,  1898,  p.  13. 

t  Sea  WiUon  <H.  P.  C),  "Foreign  Bodiea  left  la  ihB  Abdomen  atut 
l/f^pmicioaiy,"  '  Amor,  fljnwcolofpi^l  TmnMctirm*/  vol.  ix,  18W. 


VAGINAL   BTSTKRECTOMT. 


153 


at  twenty-one  ;  two  children,  otie  two  yeara  nvd  one 
seven  years  after  marriage.  Menstruation  regular  np  to 
five  months  ago,  when  the  flow  inerensed  in  quantity, 
duration,  and  frequency.  Latterly,  the  hiemorrhage  hsB 
been  almost  constant.  Four  days  hofore  adtnission  had 
a  flooding  on  rising  from  bed  in  the  morning  ;  the  hremor- 
rliage  recurred  the  next  day.  Had  eevere  eliooting  pain 
at  beginning  of  itinfas ;  none  the  laiit  few  woeka.  Dis- 
charge watery,  not  offensive. 

Patient  a  thin,  Balh>w,  ann-mio  woman.  Vagina  con- 
tracted ;  oauteri  high  up,  lips  tliickened  and  everted,  the 
whole  of  their  visible  surface  covered  with  a  soft,  eaaily- 
bleeding  proliferating  growth,  extending  laterally  for  a 
tihort  distance  on  the  vaginal  wall  on  both  sides.  On  the 
right  Hide  and  posteriorly,  the  edge  of  the  posterior  lip 
VHH  difficult  to  reach,  being  flattened  out  and  fixed  to  the 
vaginal  roof. 

On  January  22nd,  under  ether,  the  body  of  the  nierns 
was  felt  fairly  moveable  ;  cervix  lixed.  The  organ  could 
not  be  depressed  by  proRsnro  fiTiin  (ibove.  The  contraction 
made  it  difficult  to  ascertain  the  condition  of  the  broad 
bgamenb)*,  but  no  swelling  or  induration  was  discovered. 
The  examination,  as  on  pitvious  occasions,  gave  rise  to  a 
goo<1  deal  of  bleeding.  A.  small  portion  of  the  diseased 
tissue  was  removed  for  microscopical  ezatni[)ntion. 

Od  the  28th  Mr.  Shattock  reported  that  tho  growth 
was  a  gqu«moutf-ci.i|lod  carcinoma. 

Oi^oration  [February  6ih). —  (The original  intention  wag 
to  perform  supra-vaginid  amputation  of  the  cervix,  but  this 
was  abandoned  ia  favour  of  total  esllrpatiun  aa  tb»  opera- 
tion proceeded.) 

An  attempt  wan  made  to  hold  tho  uterus  iitcmly  by 
ineans  of  hooka  high  up  within  the  canal,  but  unsacceas- 
fully.  Tho  anterior  lip  was  thoreforo  eeixcd  with  a 
voUolla  ;  but  though  traction  was  combined  with  pressure 
from  above,  the  drawing  down  amounted  to  little  more 
than  overcoming  the  eversion.  An  incinion  waa  made  in 
the  vaginal  mucous  membmnc  beyond  tho  diwaijed  Kurface 

VOL.  XlXll.  It 


ISi 


TAG  I  HAL    HY8-rEKKCT0HY. 


and  the  bladder  separated.  A  similar  incision  was  made 
poslerioriy  atter  seiziog  the  fHisterior  lip,  and  Uoaglas's 
poach  opened.  A  ittout  silk  ligature  was  now  passed 
through  the  upper  part  of  the  cervix,  and  a  further  attempt 
moilD  to  draw  down  the  ntenia,  hut  without  success.  The 
Ittft  broad  ligamunt  was  with  much  difficulty  ligatured  in 
ill  Kccliuns,  and  the  lateral  attacliments  divided.  A  etniug 
ilircad  was  nov  passed  through  the  body  of  the  uterus  and 
traction  made,  but  the  organ  would  not  more.  The  cel- 
lular tissue  at  the  basd  of  the  right  broad  ligameut  waa 
therefore  secured  with  a  ligature ;  but  ia  dividing  the 
cervix  from  it,  part  of  the  diseased  portiou  was  unavoid- 
ably left  in  tlio  Biump.  Still,  the  uterus  could  not  be 
morod.  The  hand  w&b  therefore  passed  into  the  peri' 
toncal  cavity  and  u  nuinber  of  peritoneal  adhesions  of  the 
right  tube,  ovary,  nod  broad  ligament  gently  separated. 
This  eet  the  uterux  free;  the  ligature  and  eepsration  oE 
the  right  broad  ligament  were  completed,  and  the  uterus 
removed. 

1*he  operation  laBted  no  lees  than  three  hours  and  forty 
minutes.  During  the  last  hour  the  patient  had  been  in 
an  alarming  condition.  The  vagiua  was  tamponed  with 
iodofonn  gauze,  and  wood-wool  pads  were  placed  over  the 
Tulva. 

lu  a  few  hours  the  patient  rallied,  and  in  twenty-four 
hours  she  wna  able  to  pass  urine  voluntarily.  Aftor 
forty-eight  hours  the  temperature  rose,  and  the  tampon 
was  therefore  removed.  It  was  found  to  be  highly  offcn- 
Bivo.  The  tampon  was  not  renewed.  Next  day,  the 
temperature  waa  under  100°,  and  the  general  conditiou  was 
Batlafactory.  Two  ligatures  came  away  from  the  left  broad 
ligameut  on  the  twelfth  day  aod  two  more  from^  the  same 
side  on  tho  Ihirtt'cuth.  On  the  latter  day,  a  piece  of 
loose  dead  tissue  also  camo  awny. 

The  patient  left  tho  hospital  on  the  15th  of  March. 
She  had  at  that  time  a  slight  purulent  discharge,  and  the 
ligatured  ou  the  right  side  had  not  yet  separated  j  but  her 
genenirl  couditiou  was  excelleut,  and  the  wound  had.  con- 


TJlQIHiL   BYSTKHECTOMT. 


155 


h'acte^  tn  verjr  smnll  dtmensiaQ9  and  presented  a  liealthy 
Bppearii  iice. 

Description  of  Parts  removftd, — On  the  left  side  the 
uterus  lias  Ij&en  lemoved  «t  its  junch'nii  with  the  hroad 
ligament,  but  on  the  right  side  a  portiou  of  the  cervix 
18  missing.  Nearly  tbo  whole  of  the  cerrix  is  invulved 
in  the  disease,  the  infiltration  rea«hin^  Hhaost  to  the  ob 
internnm,  but  not  beyond  it.  The  disease  has  spread 
into  the  connective  tisiiue  at  the  bane  of  eairh  broad  liga- 
ment. A  8nb peritoneal  tihrciid  about  the  size  of  a  walnut 
is  sttached  posteriorly  to  tho  lelt  corner  of  the  fundus. 

Bemarke. — The  difficulty  of  the  operation  in  this  case 
vtiB  due  piirtly  to  the  fact  of  the  disease  having  extended 
more  deeply  than  was  suspected  into  the  connective 
tisHne  at  the  b&se  of  the  ri^ht  broad  ligBment,  but  ittill 
more  to  the  extensile  adhfaiima  in  the  neighbourhood  of 
the  right  hrond  ligament,  the  result  of  old  pelvic  peri- 
tonitis. Tlie  fact  is  that,  slthongh  the  case  has  done 
well,  it  was  iinsiiit'nble  for  operntinn.  I  had  not  attached 
eutticient  imporlance  to  the  immobility  of  the  cervix. 
Every  obbo,  utipccially  in  a  man*a  early  experience,  teaches 
eomo  vslaubic  lesson. 


Cask  4. — Emily  S — ,  aged  47,  married,  was  admitted  into 
St.  Thomas's  Hospital  February  4th,^  1890. 

Family  hi.ttory  good,  except  that  mother  id  said  to  have 
died  from  cancer  of  the  leg.  Catamenia  commenced  at 
the  age  of  eighteen,  aod,  aftFer  crai^ing  for  a  year,  continued 
reguhirly  and  pninlei^sly.  Flow  scanty.  Murric-d  ut 
tweQty-«ight ;  nine  children,  the  last  six  yeant  ago  ;  hna 
not  menstruated  aince.  Patient  has  recovered  wull  from 
her  confinements,  and  has  had  no  senons  illness. 

She  first  presented  herself  on  Oct.  12th,  t8t^9,  aa  an 
ont-patient.  She  then  stated  that  for  the  past  mouth  abe 
had  noticed  a  slight  yellow  vaginal  discharge,  which  was 
occasionally  offensive.  There  was  no  paiu  complained  of, 
and  no  heemurrhage  except  after  coitus.  A  suitpicinns 
roughnctis  was  at  that  titno  detected  within  the  cervix  ; 


15C 


r&OISAL  STiTBBBCTOUr. 


110  unlieallhy  nppoaraTico  oiitsido  tlio  borders  of  the  oa. 
Tho  condition  iiTnlorwent  nonppn.ront  change  until  January 
15th,  1890,  wbon  tho  putient  wah  seisiod  with  severo  pniu 
ill  tlio  luwer  purt  of  lliP  fl.b(lomen,clLii>fly  in  tho  rijijlit  iliftc 
fo!)R3 ;    t1u<  Hcl  uf  dl^ft^l:Hl<i^1U  cauxt'd  intense  pniii. 

On  udiiiissioii,  February  4fch,  tlie  pbtieiit  was  a  welt- 
nonrished,  healthy'lookiiig  woman.  On  binianaal  examina- 
tion, the  uterus  was  found  to  be  slightly  enlarged,  retro- 
flexed  and  adherent.  Cervix  obliterated  ;  os  patulous, 
inner  raorf!;iii  rough  and  uneven.  An  ill-defined,  tendtr 
swelling  felt  on  each  side  of  the  utoniB.  Through  tbe 
speculum,  the  lower  end  of  the  cer¥t(ml  ca,nal  had  a  dneky- 
red  uneven  appe&rance,  and  fcetid  pus  was  seen  i^suinf^ 
from  the  oa. 

A  fortnight  later  the  lateral  swellings  had  greatly  dimi- 
isbed,  and  the  outline  «f  the  body  of  the  uterus  had  be- 
come much  more  distinct  iia  felt  per  rtsctum.  It  was  stiti 
reti'oQexed  and  immoveable.  A.  carette  was  passed  into 
the  cervix,  with  a  view  to  remove  a  portion  of  the  growth 
for  micToaoopicnl  examinnlion.  Several  pieces  (one  of  the 
.  size  of  a  targe  pen),  which  must  all  have  b^en  already  de- 
tjiched  or  nearly  ao,  were  easily  withdrawn,  whereupon  a 
quantity  of  thicV  offensive  pus  flowed  out  of  the  cervix  in 
a  stream.  A  rise  of  temperatnro  (102"6''),  accompanied  with 
miiiaea  and  headache,  which  had  occurred  two  days  pre- 
viously, was  thus  uccoutited  for. 

The  fragineiits  removed  were  handed  to  Mr.  Shattock, 
who,  on  Febniavy  2!!nd,  reported  that  the  microscopical 
appearances  were  those  of  a  coliimniir-celled  carcinoma. 

Extirpation  was  thereforo  proposed  and  acceded  to. 

The  operation  was  perroriiied  on  February  27lh,  in  the 
manner  previously  dyscribed.  Some  difficulty  was  encoun- 
tered from  there  being  no  projection  of  the  cervix  into 
tho  vagina,  and  from  the  dxHtion  of  the  body  by  peritoneal 
adheHioTts  along  the  entire  breadth  of  the  fundus,  These 
adbesiona  were  separated  by  the  fingers  passed  up  posbe- 
riovly.  There  being  a  good  deal  of  oozing-  from  the  lateral 
aitflchmenis  of  the  cervix^  the  conneetive  tissue  at  the  base 


I 


VAOINAL    UreTCRKCtOUY. 


157 


I 


of  each  broaJ  lignineut  was  ligatured.  The  broad  li^montg 
were  then  compressed  by  long  platmuin<p1ated  pressui-o 
forceps,  and,  witliuut  further  ligatare  (excopt  one,  passed 
r\jund  the  uteriiiu  end  of  Lbe  Mt  tultu  and  parts  adjacent), 
the  detachment  of  thu  utmus  was  proceeded  with.  Tiia 
foroepa  were  left  in  aitu,  To  prereut  the  catch  from 
elippiiig-,  thp  handles  of  each  were  tied  round  with  a  liga- 
ture. No  taiupuii  waa  used;  the  ouly  dreaaiag  boing 
wood-wool  pads  outside  the  vulva,  kept  iii  poHitiun  hy  a 
T-hnndage.  Ko  haemorrhage  took  place  duriug  or 
after  the  detachment  of  the  uteraEi. 

The  operatiou  lastod  two  honrs  and  twenty  nitDut«H. 
The  patient  during  the  next  two  days  had  very  little  pain, 
and  scarcely  any  sickness.  Tho  forceps  were  removed  in 
forty-eight  hours.  Oo  the  fourth  day,  the  patient  was 
nhic  to  dispense  with  the  cutbotor ;  and  flatus  was  passed 
per  anuvi.  An  aperient  was  ordered,  and  the  bowula  acted 
h-cely  on  the  sixth  day.  Ou  ihe  eighth  day,  tho  discharge 
being  very  offensive,  a  vaginal  douche  of  potassium  per- 
manganate waa  ordered  to  be  given  twice  a  day.  The 
two  lignturos  came  away  easily  ou  the  thirteenth  day,  each 
with  a  slough  attached.  Patient  very  well  and  cheerful, 
sitting  up  to  tier  mt-uls.  Ou  the  seventeenth  day  avaginul 
examination  was  made.  Tho  vaginal  wound  admitted  two 
fingers,  and  had  a  pcrf«et1y  smooth  bordor.  The  Bugors 
p«ts&ed  through  it  into  a  closed  pou<.*h  it  bout  two  indies  long. 
The  convalescence  was  oe  frutt  from  pyrexia  as  a  normal 
puerperiniu. 

Detcriytion  of  Parts  removed. — The  lower  part  of  the 
cervix  has  been  destroyed  by  tho  disease,  so  that  its  luwest 
extremity  has  an  irregular,  ragged  appearance.  Ou  the 
right  a  portion  has  either  crumbled  away  or  been  tarn  off. 
The  di»ease  has  infiltrated  up  to  and  beyond  the  os  in- 
ternum. The  mucous  membrane  of  the  body  is  blood- 
stained and  ulcerated  in  patches  over  its  whole  extent'. 
Many  of  the  ulcers  have  ragged  borders,  and  from  their 
surface  are  8(.>en  euiall  rounded  projuctiuns,  of  the  size  of 
a  pin's  head.      Tho  muscular  tissue  of  tho  body,  except 


VAOINAL    HVSTKRECTOMT. 


Dear  tbe  os  iiitemnin,  ilnes  not  appear  to  he  hifiltiated 
witli  new  growth;  but  it  is  (I'dt'tnatoua  tbrougliuiit,  aud 
here  Biid  th&re  are  seen  jellow  alreaks  biLving  tbe  appear- 
ance of  fat.  The  peritoneum  along  tlie  wbule  breadth  of 
the  fundua  posteriorly  shows  nunierouH  ecchjiuoaes,  ntid 
slireda  of  adherent  meoibrane.  The  titema  has  been  re- 
moved olo&ely  np  to  the  wall  on  both  sides. 

JI'ii<ioio(iicol  rfj'ort  hij  Mr.  Shathrk, — The  disease  ia 
typical  camaoDiQ,  arising  in  the  uterine  glands.  The 
upper  lituit  of  the  disease  carrespoTids  to  a  line  three 
ceotimetres  from  tbe  top  of  the  uterine  cavit^',  and  one 
centimetre  above  the  level  of  the  os  uteri  internum.  What 
remaina  of  the  glitndnlnr  structures  above  tlii^  poiiit  18 
normal,  but  most  of  the  mucous  membrane  bus  boeu  de- 
stroyed by  ulceration,  the  epithelium  having;  entii^ly  dis- 
appeared, Willi  the  (greater  pnrt  of  the  glands,  the  deeper 
extremities  of  which  are  the  oulj  portion  remaining.  A 
considerable  amount  of  extra%*a»4ated  blood,  of  old  date, 
is  seen  in  the  remains  of  the  mucous  memhriine.  There 
is  no  iadicutioD  of  malig'uaut  change  in  the  diseased  mu> 
coua  membrane  of  the  body. 

Bemarkn. — This  was  the  first  case  in  which  I  employed 
clamp-forcepH,  instead  of  ligatures,  for  securing  the  maioi 
portion  of  the  brond  ligamenta.  The  rcault  was  entirely 
satisfactory.  The  largov  nnioimt  of  sloughing  produced 
seems  to  mo  a  diEtinut  advantage  in  cases  of  cancer.  It 
was  also  the  first  time  that  I  discarded  the  use  of  internal 
dressings, 

denrrul  Remarks. — In  bringing  these  cases  before  the 
Society,Iam  notnnmitidfulof  thediHcnsHionlhatiutheearlj 
port  of  the  year  1H85  followed  the  reading  of  Dr.  William 
Duncan's  abte  communication  on  "  Total  KjLtirpation  of  tho 
Uterus,"  orof  the  fact  that,  with  twoexceptions  (SirSpenoer 
Wells  and  Dr.  Graily  Hewitt),  every  speaker  whotook  part 
in  that  discussion  agreed  with  Br.  Duncan  in  condemning 
the  operation  as  unjustifiable.  One  of  the  chief  grounds 
for  this  wholesale  condemnation  was  the  high  mortality  o£ 
the  operation.     Dr.  W.  Dunca-u  collected  all  the  cases 


VAOItTAL  HVSTEKICTOHV. 


159 


lie  conld  find  recorded  up  to  that  date,  276  in  nuraTior, 
and  found  the  tntnl  moi-talit;  to  he  28"0  per  ceat.  But 
alt1ioug}i  tlie  effect  of  tliat  di»cu»air>n  was  to  checlt  the 
perforniarce  of  the  operation  in  this  country,  so  thdt 
comparatively  few  cases  have  been  publisiied  Rince,  the 
gynrecotogiels  of  otlier  countries  hare  been  under  do  euoh 
deterrent  iiifluCBce.  The  cousoquence  is,  as  we  mij;rlit 
expect,  that  the  mnrtftlity  has  been  already  considerably 
reduced.  Keen  nt  th&t  time  Dr.  W.  Duncan's  estimate 
was  probably  too  high.  The  true  mortnliiy  of  an  opera- 
tion is  not  to  be  arrived  at  by  including  every  case,  Iiow- 
erer  inexperienced  tlie  operator,  but  by  taking  the  reaulta 
of  the  best  operatora,  and  those  of  largest  experience.  In 
Dr.  William  Duncuu'e  list  there  are  no  fewer  than  thirty^ 
five  operations  by  racii  who^e  experience  was  limited  to  a 
single  case.  Marliu  collected  the  reeults,  up  to  the  end 
of  lH86f  of  the  six  Gerroan  operators  who  had  the  largest 
exporiouco,  and  foimd  their  mortality  to  be  lo'l  per  cent, 
(31!  cases,  with  47  deaths).  But  even  this  has  Kioeo 
been  greatly  improveJ  upon.  In  his  reply,  at  the  oiose 
of  the  disL-usKioti  to  which  I  have  just  allnded.  Dr.  W. 
Duncan  expressed  himself  as  feeling  "  sure  that  increased 
eitperiencc  would  never  bring  the  mortality  down  from 
28  per  cent,  to  that  which  follows  supra- vaginal  amputa- 
tion, namely,  7j  per  cent."  Huw  do  the  Egures  stand 
DOW  F  At  the  Third  Congress  of  the  Germau  Gyiioico- 
logical  Society,  lieM  nt  Freiburg  in  June,  1889,  Miiuch- 
moycr  reported  that,  in  160  cases  oE  total  extirpAtion  of 
the  oterus,  performed  at  Dresden  between  the  years 
188S-89,  the  total  mortality  was  5'4  per  cent.  Forty- 
eight  of  these  ca«ea  had  already  been  reported  by  Letipold. 
Of  the  last  112  operations,  52  were  per/vTmed  in  guccetmion 
without  <i  single  death.  In  80  oE  the  100  cascN,  the  opera- 
iioD  WHS  undurtaken  for  canocr ;  only  foar  of  the  patients 
died  from  the  effects  of  the  operation.* 

la  the  same  year  (1889),  Kaltenbach  reports  sixty-two 

•  ■  Arcliir  for  OynUologitv'  B.l.  t»xvi.  ttea  llofi,  Bsrllii,  1889,  pp.  4X4, 
tl  **q.i  *-ai  '  Cdntralliliktt  f.  OynSkol.,'  Aug.  Srd,  ISSa 


160 


•TACIKAL  BVSTKHICC'rOMT. 


cases  of  total  cxtirpa^tioB  of  tlie  uterus,  with  two  deaths ; 
one  from  liubliinatc-poieoiiiiig  in  &  puik'ut  with  pyelo- 
nephritis of  one  kidney  and.  atropliy  of  the  other  ;  the  other 
f  rum  injury  of  the  ureler  and  proJjabiy  also  of  the  bladder.* 

Turning  to  France,  wo  End  that  I'ean,  in  the  yeara 
1886-7,  extirpated  the  uterus  for  cancer  in  tweuty-two 
cases,  with  seven  deaths;  while  of  the  sixteen  operated  upon 
in  the  first  eeven  mouths  of  1888  not  one  died.f  What- 
ever may  be  the  ultimate  verdict  of  the  profession  with 
regard  to  thh  operation,  it  is  evident  tLat  the  objection 
on  the  ground  of  its  heavy  mortaiity  must  henceforth  be 
iibandoned.  Taking'  tho  ctincer  ea^us  of  the  three  opera- 
tors  whose  statistics  I  have  just  tjuoted,  the  total  mortality 
is  7'3  per  cent.,  and  if  the  German  statistics  ulone  be 
considered,  the  mortality  is  only  428  per  cent.  If  every 
newly  proposed  operation  that  shows  at  first  a  high  death- 
i-ate  is  to  be  at  once  deuotincod  as  unjustitiable,  thero  is 
nn  end  to  surgical  iruterprise  and  Burgical  progiess.  I  do 
not  propose  to  enter  at  present  into  tho  larger  quostion  as 
to  how  far  the  operation  is  capable  of  diminishing  suffer- 
ing and  prolou^ng  life.  The  data  lor  prououucinga  fiual 
judgment  on  lliose  points  Hre  not  yet  attainable.  A  cer- 
tain time  must  elapse  after  an  operation  before  we  can 
speat  of  its  permanent  reitulta. 

If  we  take,  as  the  test  of  9ncce8«  in  operations  for  cancer, 
freedom  from  recutrenco  for  a  [leriod  of  three  years,  it 
will  be  obvious  that  most  of  the  cases  included  iu  the 
foregoing  atatistios  have  been  operated  upon  too  recently 
to  allow  of  a  statement  of  results.  This  is  not  the  ease, 
however,  with  regard  to  all  of  them.  Thus,  thirty-oao  of 
Leopold's  cases  at  Dresden  were  operated  upon  more  than 
three  years  heforu  the  date  of  M iinchmeyor'e  rt-purt.J  OE 
this  number  no  fewer  than  »ovenlecu,  or  04  percent.,  pre- 
seutcd  no  sign  of  recurrence. 

•  'ContrnlblaU  (.  Qyalkohgie,'  Nuv.  2a<l.  1S8Q. 

t  Seclieyruii  (L,),  'Traill  d'ljjil^raUiutie  t-t  d'h^iU>rM!toiuii*  ^u  !>.  voio 
vt.Kiin-U,'  P»ri.,  1899,  p.  649. 
I  '  Aicbiv  fur  Oyoaku logic.'  Band  xix.  BetBu,  1887,  p.  401. 


I 


VAQINAL  HYBTICHECTOMT. 


lai 


If  we  agree  with  Dr.  John  Williams  and  uthers  that  it 
is  justifiable  to  consider  a  case  cured  it'  lino  years  have 
elapsed  without  a  recorreucej  the  propoption  of  cares  will 
appear  still  more  rcitinrkable,  for,  of  forty-two  cases 
operated  upon  more  than  two  years  previously,  27,  or  64*5 
per  cent.,  remaitied  well.*  These  results  cannot  but  ha 
regarded  as  moat  encouraging,  and  the  record  of  the  suc- 
ceeding yeai-3  promises  to  be  equally  satisfactory. 

There  is  one  point  in  regard  to  the  pathology  o£  oerrioal 
cancer  as  to  which  two  of  my  cases  (Noa.  1  and  4)  appear 
to  mo  to  furnieh  evidence  of  aome  value.  I  refer  to  the 
qnoation  whether  cancer  of  the  cervix  does  or  docs  not 
tend  to  spread  upwards  Into  tho  body  of  the  utorna.  In 
both  the  cases  just  named  {each  of  them  being  of  the 
columnar-celled  variety),  an  examination  of  the  specimens 
and  of  the  sections  kindly  prepared  by  Mr.  Shattocfc  will 
show  that  the  disease  had  distinctly  invaded  the  body  of 
the  uterus.  It  is  maintained  by  the  advocates  of  supra- 
vaginal ampututioa  of  the  cervix  for  cervical  cancer  that 
the  disease  exhibits  little  or  no  tendency  to  invade  tho 
body  of  the  ntenie,  and  that,  mainly  for  this  reason,  total 
extirpalioD  poaseBses  no  advantages  over  the  partial  opera- 
tion in  the  treatment  of  this  affection.t  The  point  ia 
of  great  practical  importance,  and  every  case,  capable  of 
shedding  light  upon  it,  ought  to  be  recorded.  It  is  true 
that  the  minor  operation  may  be  extended  so  as  to  in- 
clude the  removal  of  a  portion  of  the  body  of  the  uterus, 
and  Dr.  John  Williams,  an  nncomproniisiag  eupporter  of 
this  operation,  even  speaks  of  carrying  the  excavation  of 
tho  body  so  far  aa  to  leave  a  mere  shell.  But  surely 
this  is  to  make  the  lesser  operation  as  formidable  and  diffi- 
cult if  not  actually  as  dangerouR  aa  the  greater.      More- 

*  rt  may  bo  w^ll  to  ilnto  (hat  Wfurc  thi-'X'  fs|;iireH  wi-iv  publixhcil,  orerjr 
onpnf  tlir  pideiiU  ua«  roiuiDiinii'fttcd  with  rithiT  dij'cotly  or  throagli  (beiT 
iDCdkHl  nttciiilunt.  Mont  of  tUuw  pri'>ciitoil  tlivnmulvci  pnnnnaUjr  tat  ex- 
•nDiiutitta  j  tlje  tevr,  (iifnts-Unl  a  incditul  rvjwrt.  In  only  uiic  itiatauo*  vrat 
no  aniwer  roc«iveil  to  tht?  Ictt«r  of  Inquiry. 

t  Willuiiu«  (J.j,  UltrvuiBD  Lccturca  on  'CanMT  of  th«  Uurn*,'  Loud., 
laoa.  p.  116. 


162 


VAOINAr    mr«TEBBCT01IT. 


over,  this  extensive  bollowing  out  of  the  body  of  the  otorne 
is  not  ordinarily  practised  in  supra-vaginal  amputation  of 
the  cervix,  and  does  not  form  a  recognised  part  of  the 
operation.  Indeed,  it  is  difficult  to  see  wty  it  has  been 
Buggested,  if  it  be  true  that  cancerous  disease  of  the  cervix 
has  no  tendency  to  grow  towards  the  body.  If,  on  the 
other  hsriid,  fnTtherobeervatioQ  shoald  show  that  early  ex- 
tension of  the  disease  upwards  into  the  liuily  is  an  event 
of  not  ancommon  occurrence,  ataay  rare  iu  cases  of  oolum- 
nar-oelled  carcinoma,  it  will  scarcely  be  mnintaincd  that 
supra-vaginal  amputation  of  the  cervix  ia  as  thorough  and 
satisfactory  a  mode  of  removal  as  total  extirpation. 

"With  regard  to  the  alleged  early  implication  of  the  para- 
metric connective  tissue,  I  may  point  out  that  this  haB 
recently  been  called  in  question.*  I  do  not,  however, 
propose  to  go  into  this  matter,  because  it  does  not  really 
affect  the  question  as  to  the  relative  advantages  of  the  two 
operationa.  In  neither  the  one  nor  the  other  are  we  able 
to  remove  any  considerable  amonat  of  the  Burrouiidiag 
coDQective  tissue,  and  any  argiimont  founded  on  the 
special  liability  of  this  tissue  to  be  invaded  would  tell 
equally  against  both  operations. 

I  am,  of  course,  perfectly  well  aware  that  the  evidence 
afforded  by  two  cases  as  to  the  early  iinplicatiou  of  the 
body  of  the  uterus  is  far  from  being  conclusive.  Never- 
theless, specioieDB  of  cancer  of  the  cervix,  in  a  compara- 
tively early  stage,  and  removed  not  in  the  post-mortem 
room,  bat  from  the  living  body,  are  sufficiently  rare  to 
give  even  a  single  specimen  a  certain  value.  And  the 
fact  of  the  dieeaae  Laving  spread  into  the  body  in  both 
my  Bpecimena  seema,  at  any  rate,  to  afford  prima  fa^cie 
ground  forfnrther  investigation.  With  regard  to  miiseum 
specimens,  they,  for  tlic  most  pnrt,  illustrtito  only  thw  later 
stages  of  the  disease.  An  exoeptton  to  this,  apparently, 
18  to  be  found  iu  the  specimen  from  St.  Bartholomew's 
HoHpilal  Museum,  which  forutt  the  subject  uf  an  excellent 

*  SincltuT  (W.  J,),  "Vaginal  HjMurectoinj  for  Cancer,"  '  PnctiUuuur,' 
»M.,  1889. 


TAGINJIL    BYSTEOECTOMT. 


]6d 


iTtho^rapnic  plate  (Plate  siii,  iig.  I)  in  Dr.  Willlama's  l>t»ok. 
It  is  signiScant  thtit  iu  tbnt  sjiecimen  also  tbe  dii^iense  lias 
Spread  upwards  into  ihe  body  of  the  organ.  In  tlie  later 
stages  it  is  certainly'  the  rule  to  find  the  Itody  tuoit  or 
leas  deeply  iutpliciited.  It  is  so  in  almost  every  one  of 
tlie  specimens  in  tbe  museiira  o£  tlie  Roynl  College  of 
Surgeons,  and  it  will  b«  aceu  to  be  aoiD  the  specimens  on 
tbft  table  from  the  museam  of  St.  Thomas's  Hospital.* 

Another  point  upon  which  the  advocates  of  the  pai'tiiil 
operation  Iny  miieh  stross  is  that  when  tlie  disease  recura 
after  high  nmpiitation  of  the  cervix,  the  recurrenco  itsn- 
ally  takes  place  in  the  paramctnc  coDnectiTe  tissue  and 
not  iu  the  uterine  stump.  I  have  no  evideuce  to  offer  on 
this  question.  If  furtherobservations  should  establish  the 
truth  of  this  slatenient,  it  will  of  courKe  tell  so  fur  in  favour 
of  the  uiinvr  operation.  But  tt  will  uot  finally  dispose  of 
the  question.  There  are  other  points  to  be  couaidered 
(rui,  for  example,  the  possibility  of  ther«  being  separate 
Doilulcs  of  ennceroiis  growth  high  up  in  the  boily),  which, 
however,  it  is  beyond  tlio  scope  of  this  paper  tu  discusH. 

May  I  be  permitted,  before  I  conclude,  to  muke  two 
remarks?  Tbe  first  is  that,  while  hexitiiting,  for  the 
reasons  I  hare  given,  to  accept  bohir  of  thocnnclumons  at 
which  Dr.  Williams  has  arrived  in  hia  work  on  cancer  of 
the  uterus,  I  yield  to  no  one  in  my  admiration  of  the 
th(j roughness  of  the  clinical  and  pathological  obflervations 
npon  which  that  work  is  based,  or  in  my  gra.tituile  for  the 
many  valuable  1e>ssoiis  I  htivo  leni*nt  from  it.  Tho  secoud 
rpmnrk  I  wish  to  make  is  that,  although  I  have  endea- 
voured in  this  paper  to  show  thiit  there  are  good  reasons 
for  uot  hastily  dij^couraging  tho  treatiueiit  of  cervical 
cancer  by  vaginal  hy^tereclomy,  I  aui  by  no  meaus  ao 
enamoured  of  tho  operation  oh  not  to  bo  ready  to  welcome 
any  other  method  of  trcatiueut  that  promises  a  smaller 
immediate  mortality  and  bettor  permuucnt  results. 

*  For  detailed  doteriptioii  or  tbew  •.pecimeni,  tee  ncrt  pag*. 


164 


VAQIKAL    UVSIKKBOIOMY. 


AppShdij!  descrif/ttve  of  the  Museum  Specimens  fhown  in 
illuatration  of  Dr.  CvlUngwQrth'a  Paper. 

Specimen  1  (St.  Thomas's  Hospital  Museum,  No. 
0047). — The  nteru3  and  vagina  witli  part  of  the  Wadder 
and  urethra.  The  cervix  is  destvoyed  by  cancerous  ulcera- 
tion, the  vaginal  portioa  baviug  entirely  disappeared. 
The  vaginal  wall  is  invaded  by  the  ulcerutioa  all  round 
the  cervix.  A  zoue  of  similar  ulceration  in  seen,  separate 
from  the  above,  close  to  the  surface  ef  the  vagina  and 
reaching  to  within  an  eighth  of  aa  inch  of  the  meatus 
uriuarius.  In  fi-ont,  tLis  zona  is  au  inch  in  breadth  ; 
posteriorly,  rather  less.  The  two  sites  of  malignant  ulcera- 
tion appear  to  be  continuous  along  the  eubmucouB  tissueB 
o£  the  vagina,  the  surface  of  the  inteiveiiiug  mucous  mem- 
brane being  fur  the  most  part  uunffected.  The  disease 
has  invaded  the  tie&ues  around  the  lower  part  of  the 
vagina,  a  ring  of  infiltration  involving  the  urethra,  sides 
of  vMgina,  and  recto-vaginal  septum.  The  disease  ei- 
teudu  upw&rdti  into  the  budy  of  tha  uterus  to  within  one-third 
of  an  inch  of  the  fund  us,  affecting  the  whole  thickness  of 
the  posterior  waU  with  the  mucous  membrane.  The  same 
i»  Iruo  of  the  anterior  wall,  only  that  the  disease  does  not 
roach  quite  so  high.  Thore  ih  no  obvious  exteusiciu  of  the 
disQofie  into  the  tiHaaes  at  tlio  sides  of  the  uturutt.  The 
cancer  is  oE  the  squamous-ceUed  variety. 

Sfjucimcii  2  (St.  Tiiomus's  Hospital  Museum,  No. 
Q0<'i2). — The  uterus,  ovarioa,  and  bladder.  The  uterua  is 
¥ery  much  enlarged  ;  the  cervix  and  lawer  part  of  the  hody 
are  intiltrated  vritli  malignant  new  growth,  in  some  parts 
ulcerated  on  the  surface;  Ua:  upper  part  is  nvtHarly  affected, 
though  a  sjnaii  part  of  the  mtmtular  strvcture  there  appears 
to  hf.  heuUhy.  The  cavity  oi  the  body  is  considerably  en- 
larged by  uiceratiou  of  the  a^eeted  mucous  membrane  and 
muscular  tis^iuo.  The  oonucctlvo  tissue  on  all  sides  is 
deeply  involved.  The  growth  in  the  anterior  wall  of  the 
cervix  ha«  extended  to  the  bladder,  EoroiiDg  a  prujcctiou 


TAarSAI,    RTHTKRKCTOMT. 


165 


into  its  cavity.  The  disease  extt-nJs  downwarfJs  fo  as  to 
involve  a  portion  of  the  vnginaand  contiguona  porliona  of 
the  left  ureter,  the  bladder,  and  the  iirethrft.  The  right 
ovary  is  healthy  ;  the  left,  which  ia  closely  adherpnt  to  the 
litems,  is  the  seat  oF  carcinomatons  infiltration,  by  which 
it  18  increased  in  sizolothatoE  a  largfe  nntnge.  A  portion 
of  largo  intestinci  adJiores  to  it,  but  does  not  appear  to  havB 
been  invaded  by  the  disonsu. 

Under  the  microscope  it.  is  now  impossible  to  say 
whether  the  growth  is  a  sqnamoua  or  a  cohitDDar*cell>ed 
care  in  omit. 

Specimen  3  (tit.  Thomas's  Hospital  Museum,  No.  oq53), 
— The  uterus,  vagina  and  bindtler.  I'he  cerri.^  and  /oirer 
part  of  the  body  of  tke  utenis  are-  ci?mpletely  destroyed  by 
cancerous  uk'eration,  the  growth  involving  tke  mwenlar 
tianne  ahoiw  ifie  iileeration  In  wUhin  an  irtrh  of  thn  findns. 
The  poalerior  wall  of  the  bladiler  is  involved,  and  a  noni- 
miinication  exists  between  the  bladder  and  vagina.  There 
ia  no  invasion  of  the  broad  ligament)!  exrept  the  connec- 
ti\-e  tissue  at  their  base  immediately  coutiguous  to  tke 
cervix. 

The  disoMSo  is  shown  tinder  the  microscope  to  ho 
cohimnnr-eelled  carcinoma. 

Specimen  4  (St.  Thomas's  Hospital  Museum,  No.  b<iS7). 
— The  uterus  and  bladder.  Tlio  whole  of  the  cervix  and 
the  low^r  part  of  the  body  of  the  uterus  aru  ()e»ti'oye>d  by 
cancerous  ulcenitiou,  the  new  growth  haviof^  extended 
upwards  I'ji/o  the  hxly  of  the  utffru«  lo  within  a  quarter  of  an 
inch  of  the  fwidiut,  and  downwards  into  the  upper  part  of 
the  vaginal  wall.  The  tisauuH  around  the  cervix,  including 
the  ponterior  wall  of  the  bladder,  are  invaded.  Tho 
lower  part  of  the  right  broad  ligament  is  involved  ;  tho 
left  broad  ligament  is  fr&e. 

The  carcinoma  iu  shown  microscopically  lo  be  of  tho 
equamous-celled  variety. 

Specimen  .5  (St.  Thomna's  Hospital  Museum,  Nn.  OO.50). 
— The  uterus  and  vagina,  with  the  bla«ider  and  rectum. 
The  body  of  the  uterus  is  a  little  enlarged,  and  the  lower 


im 


TAaiKAL  HYSTEKECTOHT. 


part,  Up  to  a  point  half  an  inch  aboite  tke  o9  internum  and 
au  inirh  and  a  quarti^r  b«low  tho  funduti,  iu  inHUrated  with 
cancerouB  malter.  The  lower  part  of  the  cervix  is 
destroyed  l>y  ulceration.  Tlie  vagina,  oxoept  Mt  its  lower 
part,  is  similarly  destroyed,  and  in  its  pUice  is  a  largs 
ill-defined  cavity,  into  which  the  bliidder,  uterus,  and 
rectum  open.  The  lower  portion  oE  the  nrethra  remnins, 
but  is  uricotinected  with  the  bJadder,  the  lower  part  of 
which  13  destroyed.  The  anus  is  entire  ;  the  rectum  opens 
into  the  common  cavity  by  two  apertures,  one,  two  inches 
above  the  aiiti»,  tho  olhor,  five  inchoB  above. 

The  specimen    is  shown    by   the    microscope  to    bs   a 
squamous- celled  carciuotuHj  with  uests. 


Dr.  John  Williams  expr^Baed  hie  high  appreciation  of  Dr. 
Oullingwoirt.h'a  papier.  Tbe  qiiesttun  raised  in  it — the  treat- 
ment  o(  paropr  of  the  (inrvis  of  the  ut^ruB — was  of  vflry  great 
importiinct:.  In  coming  to  a  conclusion  upon  it,  rui:;iird  nhould 
Iw  had  to  two  tiiiuys ;  (1)  thi-  direction  of  gruwth  of  <mticer 
when  it  hf^au  in  the  wrvis,  luid  (2)  the  difference  in  tin;  rexulla 
ohliiiuvd  afti^r  totu.1  extirpation  i>f  the  uterus  aad  supra-vaj^inal 
amputal ion  uf  tlie  cervix.  With  regard  to  the  direction  of  the 
growth  of  cancer  of  the  cervix,  it  had  been  maiDtalned  that  its 
tendency  v/oJi  to  aprood  outwards  towards  the  parametric  tiesue, 
If  the  disL-aae  began  near  the  external  orifice,  it  apread  upwards 
and  outwards;  if  it  be^Hu  near  the  inl^rnal  orifice  it  spread 
downwards  pud  outwards,  so  as  in  each  oiso  to  involve  the 
whole  of  the  cervix  j  but  it  showed  no  tendency  to  invado 
thi-  liody  cif  the  uterns,  and  coiisetjuently  invaded  ttiis  [lart  only 
in  iidvanoed  stiiges,  when  the  paraiiit'lric  tissue  had  been 
affected.  The-  object  of  Dr.  Cullinjfwortb'a  pa[>er  waa  to  ehow 
that  cancer  of  tho  cervix  invaded  the  l>odyat  an  e&rlier  period  than 
that  just  statad,  and  that  consequently  total  extirpation  of  the 
uterus  waa  an  operation  preferable  to  supra-vagiual  amputatioa 
of  the  cervix  in  tfaia  dijieaae.  In  eupport  of  this  view  he  has  exlii- 
l>ited  some  half-a-doien  spccinienBof  the  pelvic  organs  of  women 
who  bad  died  of  eancer  of  the  cervix,  and  i>iveii  records  of  four 
cases,  aecompimicd  by  specimens,  in  which  he  hud  pitrfonued 
total  extirpation  for  cancer  of  the  cervix.  Now,  whfLt  did  these 
apecinienB  show?  The  half  dozen  taken  from  the  body  after 
death  (and  every  hoapital  museimi  in  London  contained  uny 
numlM^r  of  aneh  specimens)  sb^iwed  thia  :  that  in  (tach  onu  of 
thuui  tUu  body  of  the  uterus  wa«  left  almost  if  nut  quile  in  its 


TAQIHAL    BySTBUBCiOUY. 


167 


entirety,  whil«  the  cervix  had  completely  clisappoarod  ;  that,  Ibc 
coDitective  tissue  arouud  Ihecorva,  that  id  lb()  bMe  of  tbc-  broad 
ligament  and  ihat  aroimd  llie  U|jp«.T  i^art  of  ibe  vaK>i">-  b'l-d  Uxta 
eatan  &va.y:  iliat  tlieLbiidi*!'  or  the  reitiimor  h<Ah  liiul  bui-u  in- 
Tudcd:  iLud  that  th«  result- vf  tlie  disease  bad  bi?eu  la  form  il  Iitrgo 
caTily  in  the  ntrufture  of  tjie  wrrvix  and  itM  surroiindiugB,  and  to 
k<avL'  lln^  IkkIv  of  Mil'  nteriiH  jilinost  in  itx  eutirvij.  What 
atroiifjer  ovideiiw  cuiilil  [iiivi?  luH.;!!  Imiitfjlit  forwiLi'd  lo  sbow  tbat 
the  body  vi  tbv  utcrua  viae  Dot  a  mors(.-l  to  tbu  tital«  o£  <.-uuo^-^  of 
the  feirix.  and  thB-t.  aincL-ir  of  tlif  ctTvii  rcvelk-d  in  ibe  |iiiraiue< 
triuDi,  but  WHB  diiiinclincd  to  invajle  th«  uIltiup  body  '^  But  what 
did  the  four  caaes  which  formed  tlie  baaos  of  thi>  pajier  show? 
Oae  of  tb^in  was  a  case  of  squamoug  epitbfliuma.  Tije  diHt-uj^e 
in  ibis  iiistAQoe  waH,  as  usual,  <)uiti>  supi^rticial .  being  only  half 
an  inch  in  depth— but  il  bud  sprt^iid  beyond  the  cervix  on  to  the 
Tft^iinl  wall.  tliuH  eliowing,  as  l]»d  been  before  pointtiJ  out,  tbut 
thedirectionuf  growthof  HquiiniO'iis^pitbt^ltoinaof  the<.'irrvix  wu8 
snperficiiLl,  Hud  oii  to  uud  ulon)^  the  vu^iiDLl  walls.  Ttit<ra  wnu 
u»  eusjjiciou  that  the  dis'.uee  bud  inviidt;d  the  body  ia  this 
cji«e,  and  yet  the  whole  uierua  was  removed.  In  the  other  three 
cases  Ibe  ei^rciic  of  ihe  utj?ru8  was  so  eoRi|dctely  diseaspd  that  it 
WM  found  inipossild?  tft  t;rip  the  uterus  during  the  oj^eration, 
for  by  reason  of  ita  friability  it  broke  dowti  bit  by  bit.  IiJxauii- 
DAtioQ  of  ihij  or^an  showed  that  tbt'  whole  thit^tceiiin^  nf  the 
««TTix  was  eunf^Tous,  and  that  tho  pnriinietrio  tiaxuo  had  been  in- 
Taded.  So  that  tbvitt-  cases  wcr«  cxamplca  of  cancer  in  aii  advanc'ed 
Btag>>,  in  which  no  openition.  and  k-asl  of  all  Buth  a  ikriong 
operation  a*)  lotiil  extirpation  of  the  uturuw,  was  juatifiablo  (iii 
Myiiig  this  Pr.  Williaine  *])oke  with  the  advantage  of  having 
rsamined  the  orpins),  for  it  gave  the  pntient  not  tbn  faintest 
chance  of  a  radical  cure,  and  an  operation  of  such  ntiignitndij  as 
total  extirpation  fibould  never  he  uadertakeu  as  a  palliative 
meiiBure.  But  even  iu  these  spi-cimeiiti  of  Eulvaiiced  cancer  bad 
the  disvaKi-  irassed  the  inner  orilici<  and  invaded  the  liody  P  T>r. 
CuUiDgworth  in  bin  paper  stated  thut  the  seelions  under  tho 
ii)icn>BCO[>e  showed  that  it  had.  Dr.  WiUiania  bad  examined  this 
MVltonn  and  fonnd  in  them  no  evidence  one  way  or  the  other. 
Indeed,  the  seetiunn  showed  nothing  except  cuui^r  in  an  organ 
largvly  compoHcd  of  niuscuhir-libn.'  cells;  luey  showed  ao  struc- 
ture charucteristic  of  the  body  or  the  t-ervix  of  the  uterus.  On 
eiaminatioti  of  the  or^ns  theintielves  he  could  find  no  evidence 
that  the  disease  had  passed  the  inner  orifice.  Owing  to  th« 
ulocmted  state — which  was  admitted  not  to  Ita  cancutoua — of  ono 
of  them,  it  was  jierhaiw  impossible  to  deeide  this  point,  With 
regard  to  the  other,  he  could  find  no  evidence  that  tbs  diaeaao 
hita  imeuied  beyond  tho  limits  of  the  cervix  in  the  direction  of 
the  body,  while  it  was  clear  that  it  bad  in  all  theifecusfH  invaded 
the  parametric  tissue.     The  specimen  exhibited  by  the  Pivsideut 


108 


TAOINAT.    nTaTKRBCTOMY. 


bad  cl«iHy  passed  tlic  internal  tirifico,  but  ia  tlile  case,  apain. 
canci^r  waa  iti  an  mlvmicad  stopt?,  for  it  liail  iDViuied  the  cellular 
tiflsiic  a.romi(l  the  cervix  and  niii.de  th*  eaee  (|niti>  unfit  f  nr  opera- 
tive mpUiSurt^s.  l>r.  Homiau's  siifcimm  IwlonseJ  to  n  clasa 
whioh  bafl  been  desprilwd  by  Dr.  Wlliams  from  its  earliest  to 
itB  latest  stwffes.  and  wns  in  that  stage  in  wbicli  opemtive  pro- 
oeedinei*  did  imttjiiifc  but  harni.  3i)  tb&t  «very  one  of  the  apeci- 
BlMlfl  esLibitjrd  to-tii^ht  vfnt  tAt  pri>ve  tliiit  cancer  of  tbe  cervix 
showed  a  tpndi>Ticy  to  j{row  nnlwarda  t^wai-ds  the  parametrium. 
ftiid  invuded  tbo  bo<ly  in  the  later  s^-ngeg  only.  The  result*  ob- 
tiiined  nfter  tobil  extirpation  and  supru^vaginal  umputaltun  of 
th«  cervix  went  to  show  the  same  thing.  After  aupm-Tf^inal 
amputation  recurrencre  took  place,  not  in  the  atumpuf  the  uterus 
left,  biit  in  l,lie  celliikr  tin8ue  around  (tlip  except ioiiB  to  this  wcro 
rare);  and  after  total  eitirpatioo  it  orciirreil  of  course  in  tlie  samo 
place,  and.  if  stat.istieaof  rhe  aame  period  bo  taken,  far  more  fre- 
quently. Thid  may  possibly  be  explained  by  the  fact  that  total 
extirpation  was  at  one  time  perfurm^ed  under  a  false  impresniou 
of  tbe  patholopy  of  cancer,  for  tho  more  severe,  wbile  8i)pra* 
TftfipnR.!  Hinpntation  was  adopted  in  leaa  severe  cosea  It  smmed 
to  Dr.  Williams  that  if  the  recurrence  after  supra-vaginal  ampu- 
tation tnok  place  in  the  cellular  tissue  and  not  in  the  nterins 
Rtump,  total  extirpation  presented  no  advantages  over  tbe  lesa 
Severe  operation. 

Dr.  WnxiAM  Dcncas  did  not  Ihinlt  that  earwr  of  the  cervix 
uteri  tended  to  spread  up  into  tbo  body  of  the  utenia  until  (io 
tbe  great  majority  of  cases)  it  bad  previously  iiifiltnited  the  cel- 
hilar  tissue  outrtiile  tbe  ulerua.  Ke  waa  qiiit^  of  Dr.  John 
Williamn'a  opinion  that  tbe  many  niuseuiit-^pei'irtienH  nowabowii 
cle.irly  support**!  this  view,  for  althoncli  tho  spenimens  wero 
tb(ie«  of  cuDcer  iu  the  latest  staRc,  the  uterino  body  was  in  most 
of  tbecn  apparently  un>tffeL'ti>d.  Since  reading  hia  paper  on  total 
extiipatiori  of  tbe  iiteriis  lM?Enre  tho  Soeiety  in  1885,  Dr.  W,- 
Dunoan  bad  carefully  examined  everv  ca»e  of  uterine  cancer  tbat 
lie  bad  met  wilh.  In  only  three  could  lie  satiitfy  himself  tbat  the 
Iinraiuetric  tissue  waa  unaffected  and  a  radical  oi>omtioii[  advis- 
nble.  Ho  drew  attention  to  the  importAneo  of  carefully  eiamin- 
iug  tbe  utero-eurral  lij^anients  by  digital  exploration  throu^b  tbe 
rej-ctum.  for  in  many  caaea  of  cancer  in  nliicb  the  ordinary  hi- 
inaniml  examination  showed  the  uterus  to  be  mobile,  yet  either 
one  cr  both  utero-sacrat  liKanients  proved  to  b«  thickened  from 
oruiceroiiB  mfiltration.  This  thickening  could  only  be  det«c(ied 
on  TPctal  eiamination.  and  of  course,  wlieuover  found,  absolutely 
Bontra-indirat^'d  operations.  He  asted  if  Dr.  Cnllingwortb  exa- 
mined by  tlio  rectum  iu  bis  cases,  ub  the  fact  that  in  some  of 
them  till' Uterus  could  not  be  drawn  down  with  a  volsellu  seemed, 
in  Dr.  W.  Duncan's  opinion,  to  prove  that  tho  cancer  was  not 
liniited  to  the  uterus  at  the  time  of  operatiou.    With  re^rd  (o 


iVs 


TAOmAL   BTSIIBECTOHr. 


169 


tho  conipnmtivp  risbs  of  tnt&]  extirpation  hdJ  sujirs-vagiiial  am- 
putatton,  Dr.  Duticon  rt^rJcd  foreign  statiHlica  as  tim^ticarily 
valui-lesa,  inasmucb  as  tokl  extirpation  was  performed  f<>r  ollior 
conclitious  thau  cuncer,  sUL'h  iis  prolapsus  utyri.  He  B^i]]  iiiHiii- 
taiued  tbat  in  tlie  tew  ciiscs  wLero  any  mditaJ  procedure  was 
cuIIimI  fur,  the  siipni-vii^iiiiiL  amputatiou  was  the  prcfcraltlu 
operation. 

Dr.  W.  Jai'p  SiNciAia  referred  to  the  fact  tbat  the  minor 
oprratiou  bad  been  almost  uaaniraouslj  abatitIoiii.>rl  hy  Ocrmiiui 
0[iera.tive  gynscolc^ista  us  a  point  in  favour  of  lulal  cxtirpatiun. 
A»  tins  operations  wpiv  performed  almost  (;nt.iri.'ly  in  the  public 
boKpituls,  the  Uiinnau  reports  must  Ijc  cunsidered  fully  aa  rt'li- 
bLIc  aa  any  pulrliabeJ.  He  would  confine  hb  remarks  to  the 
question  of  the  direftiou  in  which  the  diseano  of  the  uterus 
spread.  It  ^as  admitted  on  all  Lands  that  the  rcisiilta  of  total 
extirritttion  for  cancer  of  the  body  were  comparatively  favourable, 
and  it  wan  uNo  a  fact,  though  itnl  perhaps  »u  frankly  admittt'd, 
tbat  cKtirpatiou  for  cancer  of  the  portio  vaginalis  gave  also  per- 
manently Kood  rcaults.  The  least  favourable  class  of  cases  was 
t(an<»^r  of  the  cervix.  The  reason  of  the  above  facts  neernod 
ohvioiin.  In  t■■^nce^  of  Ibis  body  and  of  the  portio  vnglnalia  an 
operation  luailc  a  clean  iiwcL-tJ  of  lill  the  affecti'd  tiDstiu  at  a  con* 
Hideruble  diHtuuco  auatomiciilly,  if  not  pbyMiohtyiical ly,  from  the 
disousu.  Oa  the  oilier  Land,  in  cancer  of  the  cervix  it  was  ex- 
Irumely  JifBciilt,  except  in  the  very  earliest  caues,  to  keep  wide 
of  the  intilfrated  tisancH.  A^in,  cancer  originiitiuy  in  the  cer- 
vical eauat  was  liuhlo  to  remain  ooncealed  for  a  lurj^'ortime  than 
in  tbe  body,  where  it  causod  pain  and  dinehargo,  or  in  the  tip 
of  the  vagmnl  portion,  where  it  produced  atypfeal  hirm«rrha(;& 
It  the  cancer  were  to  spread,  it  must  do  lo  in  the  parauiulric 
etractarcB,  hut  tho  rule  wan  that  the  apreading  ocenrrt'd  com- 
pBTatively  late  in  the  proceus  of  diHcase.  Agi&iu,  the  exccpliima 
in  which  the  diaeaHO  Mpread  up  and  down  to  an  extent  which 
could  only  bo  aaeertaiued  after  opj.<ration  wore  so  numeronii  that 
the  only  nafe  rule  was  to  perform  the  major  oi)eratii>n  as  early 
na  poiiailik'.  The  openition  was  called  major,  hut  the  ttjieitker 
doubted  if  it  WOM  d»  dan^emns  an  flome  Hurgical  pr(KM:idureij  wbiob 
had  l>oon  propoBOd  an  coui]>arativcdy  Hafe.  These  latter  avoided 
wounding  the  peritoneum,  hut  tlic-y  left  lUo  eirciilatiun,  both 
batniiv  and  lyniphatie,  comparatively  uuiuterni]ited,  and  tbat 
was  asouroe  of  immcdiat*^  and  remote  daufji-r.  Dr.  Sinclair's 
experience  of  tbe  o[>emtion  now  iLuioiinle<l  to  eit^bteen  cantn  of 
total  extirpation  for  cancer,  Twelve  of  tlieiie  o]>erationH  had 
hwjn  perfonned  within  tho  last  twelve  months,  and  all  were 
olive  Bud  welh  except  one  patient  who  died  of  ai.'utc  seidie  |x.Ti- 
tonitiii.  He  gave  dutaiU  of  cases  of  extirpation  over  two  yearn 
ago  in  which  no  reeurronee  htul  tuten  place,  and  the  patient  re. 
mained  in  very  gooi!  health.  He  conobide<i  hy  eiprcsam^  strong; 
VOL.    XUXll.  12 


170  TAQIHAL   HTSTEBECTOVT. 

coQcarrence  in  Dr.  CrtUingvorth'a  opinion  of  tbe  value  of  total 
extiqmtion,  and  congratulated  the  author  of  the  paper  on  the 
conrageoue  honesty  of  his  statements  of  fact  and  opinion. 


On  the  motion  of  Dr.  Lbwbeb,  Beconded  by  Dr.  W.  S.  A. 
QsariTB,  the  discussion  was  adjourned  to  May  7th. 


MAY  7th,  1890. 

GsAiLY  Hewitt,  M.D.,  Past  President,  Id  the  Chair. 

Present  38  Fel]owB  and  10  ViBitorB. 

Books  were  presented  by  Sir  Hy.  W,  Acland,  Proi. 
Allen,  Dr.  Calderini,  the  New  York  Aoademj  of  Medicinej 
the  Guy'a  Hospital  Staff,  and  the  WestmioBtcr  Hospital 
Staff. 

Charles  Arthur  Morris,  M.A.,  M.B.,  B.C.Cantab., 
F.R.C.S.,and  Prank  F.  Schacht,  B.A.,  M.B.Cantal>.,  were 
admitted  Follows  of  the  Society. 

AlberEhrmaQD,  L.B.G.P.Lood.  (Southum],  and  Godfrey 
P.  Reid,  M.D.Dabl.  (Orange  Pros  Stato),  were  declared 
admitted. 

The  following  gentlemen  were  elected  Fellows  of  the 
Society; — Arthur  Henry  liobinaon,  M.O.Durh.;  and 
Bcglnald  Huno  Williams,  M.D.Load. 


A  UTERUS  SHOWlNOr  THE  EFFECTS  OF  A 
GANGRENOUS  FIBROID. 


By  J.  Bland  Sutton. 

In  October,  1880,  I  was  asked  to  see  Mrs. ,  aged 

iS  yenrB,  in  conRaltation  witb  Dr.  8.  L.  Smith.      A  dusky- 
red  tumour,  as  large  as  a  cocoa-not,  projected  from  the 


AXtS    FKBtWDRn    BmPAK. 


173 


the  putrid   \nii»s  romuved,  uiul  tliu  utcTiiiu  ciivity  froaly 


20W. 


irrigated  wttii  aLUliiuate  KOlutiuOj  1  lu  auyu.  for  somo 
days  the  patiout  prooiisod  to  do  well,  but  on  tlio  ovouiug 
of  thu  lifth  day  after  tho  opcratiou  tho  tomperature  sad- 
doidy  fell  fi'oiii  101°  tu  !)7",  aud  sliu  ^eouiuJ  abuut  tu  die. 
In  twolvti  lioufs  tlie  collapHe  pasaod  uff,  poritunitiu  auper- 
veuLid,  utid  death  occurred  ciiue  duys  after  the  remgral  uf 
the  fibroid. 

The  t-xnminatiou  of  the  utorus  was  very  insbnictlTo. 
Its  walls  were  greatly  hypertruphitid :  on  the  posterior 
wall,  near  the  fundus,  vftun  seen  the  I'liiiiided  etimipor  the 
tibi-oid  quite  healthy  and  Eiealod.  It  was  suiToundod  hy 
the  ulerine  mucous  mouibrane  iu  a  sloughing  condition  aud 
nearly  loose.  The  sloughing  process  had  involved  tho 
iniicoiis  membrane  of  the  Fallopian  tubou,  aud  portioua  oF 
this  putrid  ti»fiuo  liad  protruded  into  the  cavity  uf  the 
peritoneum  aud  iuduced  fatal  peritonitis.  Had  thu  abdo- 
minal oHtiam  become  occluded  by  ibe  iuil animation,  as  so 
frequently  liappcns  in  cases  of  aalpiiigitia,  this  woman 
would  probably  not  have  died, 


Mr.  Alhaj*  Dorak  ubnervwl  that  Mr.  Sutton's  spi'cimyn 
provvd  how  till'  iK'rituu*!iiui  mij^bt  Wcouu.'  iufocited  by  the 
enimncc  into  its  cavity  o£  putrid  tiubblancuH  wbit^h  ori^iniklly 
became  putrid  within  tka  uteniN  and  ]>aHNf>d  iiiti>  the  jierituneiini 
through  the  FaLlojiiaa  tube.  Sentie  jierilunitis  after  childbirth 
aud  aJEter  o|H-niliuuB  iu  the  uoit<hbuurhi>u>d  vl  thu  ccrvii,  luvBt 
probably  arose  iu  the  sauu;  wny.  that  is  by  poiHonous  fluids 
simply  paHsing  up  tha  tubes.  More  complic'a,toa  doL-trines  an  to 
peritoiioal  infection  through  intlammaliou  be>;iuuiu);  m  the 
eudumelrium,  and  t-xteudiiig  thruugli  the  inuHi'iilar  cubstutice 
to  the  perituneuui,  or  to  the  pelvic  (juaoeuLive  tJBSue  were  less 
likely  to  be  correct. 


AXIS  PHKSSUHB  BINDKB  FOK  U8H;  iJUKlNG 
LABOU  U. 


By  Dr.  AfMAai),  Ipswich  (introduced  by  Dr.  UoKituCKS], 


Dr.  Lkwe  Its  eaid  that  the  most  itnportftut  question  seemed 
to  be  as  to  whether  vagina]  hysterectomy  or  supra- VBgiiial 
aiuputution  of  the  cervix  was  the  better  operntion  for  those 
cases  of  cancer  of  the  cervix  suitable  for  radical  truatment. 
In  determining  this  questiou  tlie  two  chief  factors  to  be  con- 
sidered were— Ist,  tlio  relative  mortality  of  the  two  opera- 
lions ;  and  2iid,  the  prospect  of  immanity  against  recur* 
ronce  offered  by  each  of  them.  As  regarded  the  mortality 
in  total  extirpation,  tliurc  waH  a.  greater  risk  of  septic 
iafeotion  owing  to  tho  free  opening  into  the  poritoneum  ; 
a  much  greater  risk  of  hsemorrhage,  both  during  the  opera- 
tion and  subsequently  ;  and  COQ? plications  such  as  adhesiona 
between  the  uterus  and  intestine  or  omentum  might  be 
met  with.  Further,  as  pcgarded  the  duration  of  the  opera- 
tion, and  therefore  the  shock  experienced  by  the  patient, 
total  extirpation  compared  unfavourably  with  eupra-vaginal 
amputation.  Although  some  Gerniau  operators  reported 
the  mortality  of  total  extirpation  for  cancer  as  5  per  cent., 
no  such  favourable  record  could  be  ahown  in  England. 
Dr.  Lewers  urged  that,  in  the  case  of  an  operation  that  had 
been  extensively  performed  here,  Englieli  rules  of  practica 
ahoold  be  founded  on  English  statistics.  He  belieredf 
from  hia  knowledge  of  published  and  unpublished  cases, 
that  the  mortality  of  totaJ  extirpation  for  cwncer  in  this 
country  was  much  nearer  20  per  cent,  than  5.  Dr.  Lewera 
had  himself  performed  three  total  extirpations,  two  for 
primary  cancer  of  the  body  of  the  uterus,  which  recovered, 
and  one  for  cancer  of  the  cervix,  which  died.  He  had  pei^ 
formed  8upra-vagiual  amputation  of  the  cervix  seventeen 
limeB  without  any  death. 


VAGINAL 


HTaTBBECTOMTr 


175 


Dr.  Lewers  reminded  the  Society  that  at  its  last  luoet- 
ing  so  higli  an  authority  as  Dr.  JoHa  Williaaia  spuke  of 
t]iii  chances  of  curiDg  cases  of  cancer  of  the  uterus  hy  any 
operation  whatever  as  "  iofiiutesimal."  On  the  other 
hand,  a  large  proportionof  the  cases  operated  on  in  Gemwiny 
were  free  from  recurrence  for  so  long  a  time  after  operft- 
tion  that  if  thej  were  renlly  caeeB  of  cancer  tbey  might 
fairly  be  considered  as  cared.  The  only  possible  explanit- 
tion  seemed  to  be  that  many  of  the&e  cases  were  not  really 
instances  of  cancer.  Referring  to  his  own  series  of 
serenteen  cases  of  supra -vaginal  amputation,  Dr.  Lewers 
soddin  fifteen  of  them  the  operation  had  been  complete — 
that  is  to  8ay,  it  was  believed  that  all  the  diseaeed  tis&ne 
had  been  removed.  In  these  fifteen  cases  the  results  as 
regarded  recurrence  had  been  aa  follows  ; — Four  cftsos 
were  known  to  bo  quite  well  two  years  after  the  operation, 
six  eases  were  known  to  have  had  a  recurrence,  three  cases 
were  lost  sight  of,  aud  two  other  cases  were  free  from  re- 
currence, but  had  only  been  operated  on  within  the  last 
twelve  months. 

Omitting  these  latter  from  consideration,  and  counting 
the  cases  lost  sight  of  as  cases  of  recurrence,  there  remained 
four  cases  out  of  thirteen  well  two  years  after  operation — 
that  is  to  say,  30  per  cent.  This  result,  ao  far  as  he  knew, 
was  quite  as  favourable  as  any  obtained  hy  total  extirpa- 
tion, and  it  had  been  secured  at  no  cost  to  life.  From 
what  he  had  read,  aud  also  from  the  experieuce  of  his  own 
cases.  Dr.  Lewers  believed  that  in  nine  caeet!  out  of  ten 
the  supra-vngioat  amputation  was  the  right  operation  in 
early  casee  of  c&ucer  of  the  cervix. 


Dr.  Waltkb  Ghiffith  stated  that,  from  examination  of 
specimens  and  experience  of  cases,  he  had  formed  the 
opinion  that  the  kind  of  cancer  was  a  very  important 
matter.  The  only  cases  which  conld  be  considered  really 
favourable  for  removal  were  cases  of  epithelioma,  and  it 
did  not  make  much  difierenoe  which  operation  was  adopted 
90  long  as  the  whole  disease  was  freely  removed.     Ho  had 


loHt  ono  patient  frmu  liuii]ioi'L''h.ii.go  iiftei*  the  n-'inaval  of 
|)i'(?fj8Ure  forceps,  tbe  bleeiliii^  bogluniug  w)iil»b  I.Iig  vagina 
wa«  being  duiiclietl,  Tlio  ri«k  of  tbis  occurrence  would 
uiakb  liiiu  very  ciiutious  in  Iheir  use  in  future,  except  aa 

ttUxiUnry  uiu'iuia  to  ligutui-t-M. 


I 


Dr.  Macnauuhtun  Jonks, having  rofcrred  to  tho  iucrcusod 
respousiLiility  Ucvulviug  oii  tliouo  wbosu  iiilvice  was  swugbt 
iu  cui^eu  of  canoer  ol  tbo  wouib  in  the  face  of  tho  aacer- 
tainod  rosults  of  vn^fiiml  by sfct' recti iniy,  saiil  lilmt  hitherto 
ctiiiisi'r  (if  Uie  uti^riii^  bud  been  Uio  opjirobriuui  of  gynm- 
coliigy  ill  Uk!  futility  uf  the  vfiriuut!  opwrativc  procetluros 
piiM.' tiMLnl  for  1(8  euro,  llis  tiwii  record,  iiicliidiiig  timny 
Compli'lti  Iiigli  aiiiputatidiiH,  hud  btieii  lUL-hLiicliuly.  Ho 
argund  that  Dr.  Jubu  Williu.ms's  conclusions  as  oppu!(L>d  to 
bystt;rectomy  were  faUacious.  Tliey  might  he  dividttd  into 
tbrei;  heads — statistical,  pathuloj^csl,  and  cliuica-l.  Ah 
agaiusl  Dr.  Williams'^  assertion  that  tbe  (ici'mau  statistics 
were  prat'tically  valtteless,  being  based  on  hysterectomies 
perfoniiod  for  other  cases  than  cancer,  Dr,  JoueB  qiiotod 
tbe  stdtistic*  piibliehiHl  by  Drs.  Muiide  mid  Wella  up  to 
188!l,  Huil  t'olloet-ed  from  tbe  ru^iulbs  of  183  cawoa  of  uancer 
uptiratod  on  iti  (jonnaiiy,  Friiiict*,  Aniorica,  :ind  Eiigtuud. 
Of  lliesu  tliert-  wlm-q  Ivvwiity-two  deaths  after  operatiou,  and 
ill  only  twtnty-tbree  was  reciirrcuce  noLud  up  t.o  tht;  tim« 
of  pubEication  of  bhctio  ctisee,  and  in  thirteen  rccovory  wax 
Haid  bo  he  pormnneub,  Coiisidoi'iug  the  chnrncter  of  tlie 
operation  and  its  comparatively  recent  intvoduction,  he  con- 
eidered  tins  record  to  be  very  favouralile.  Dr.  Ciilling- 
wortb,  in  his  few  cases,  bad  himself  acknowledged  the 
advantages  of  osperioiice  in  operating — as,  for  instance,  in 
tlio  use  of  tho  forceps  instead  of  lignturo,  tbongb  Mnriiu  still 
operuteid  by  ligatnre.  Ig'iiorMuco  and  bungling,  as  even 
Mr.  IjawHun  Tiiit  acknowledged,  were  inseparable  from 
high  murlttlity  iu  t-arlicr  tipcrations  of  this  kind.  As  to 
tbe  pathological  ground  taken  by  Dr.  John  Williams,  lie 
demurred  altogether  from  the  view  that  the  disease  was 
8o  limited  as  he  declared  by  the  internal  08.    The  rcneurches 


VAOIHAI.   llveTIGKItarOHT. 


177 


of  Abol  wore  quite  oppoaed  to  this  view,  as  also  those  of 
other  autliorities.  lie  Iiad  Bt'eii  umloubtod  ciinea  where 
the  fiiiidu!^  vrns  iuvudt^d  imd  nut  Um  ]iiiramoti'ium.  Tho 
uncroJicope  was  not  ut  times  an  iiifalHhIu  test,  and  good 
liistologists  wure  liable  to  error  iit  sucli  matters.  Lastly, 
he  did  uot  agree  to  the  cliuicul  deductioui^  of  Dr.  Wiltiaing, 
Hu  cuuld  uot  Bou  wlij'  oiiu  aiirgical  priiioiplu  lihould  tti 
applied  tu  uauvcr  of  the  Lreunt  aud  nuuthur  to  citucur  uf  tliti 
uterus.  He  ugread  to  thu  pruposibioii  uf  Dr.  Lewors  that 
tho  proi9ptJi:t»  from  tho  two  operative  procedures,  hifi^h 
n.m ptitation  aud  hysterectomy,  should  be  put  plainly  beform 
tlio  |»itieut.  Fur  hiiiiKL>|[  liu  fi^lt  that  iu  ii  eana  in  whJcb 
truo  citncfir  of  the  ute^nm  wiis  oucu  cluarly  deuhiriid  in  Ibe 
corvix  uteri,  and  tho  KUrrounding  tiHsuutj  wm'u  licidtb^,  he 
ttliould  ]eau  to  the  side  uf  hysterectomy  and  not  mnputa* 
tion.  It  gave  the  woumu  the  best  chunce  both  of  pm- 
longing-  aud  siiviiig  life. 

Dr.  T.  C.  Uayes  thuLight  lliat  ciirciuouiu.  of  the  ultvIx 
had  a  strong  tendency  to  iuvude  the  body  aud  fundus  of 
the  uterus.  He  seldom  found  that  the  disease  wae  limited 
to  tbo  cervix  when  patifrnta  catne  under  obRervntion. 
Argument  againsl  viigiuul  hyHlerectouiy  based  upon  itiioh 
HmittvtiouK  being"  tho  rule,  or  oven  oonimoii,  wii.s  uusouud. 
Jf  there  were  Hssurances  of  thin  liuiitabiou,  vaginal  ex.tir- 
patiou  tihuuld  not  be  rofeortttd  to.  It  was  a  uiuvE  more 
dangerous  opL-ratLon  tbau  atuputuliou,  though  iu  the  future 
its  dnngetH  would  probably  bo  luBsentjd.  Ue  could  not  too 
strongly  urge  that  patients  nhould  in  nil  canes  bo  made 
fully  aware  of  the  scrioua  dangers,  audL  not  buoyed  up  with 
false  hopes  of  a  pormanent  care. 


Mr.  Kqektoh  Jbhninos  reuiarkud  that  lie  wonlid  like  to 
seo  broad  priuuipluo  dinuuHHed  fi rut,  and  meUiodx  of  detail 
and  cuniparisouii  between  different  uperatiuud  afterwards. 
By  Iho  courtesy  of  three  or  four  uieuibern  of  Uie  profes- 
Rtou  who  had  auttwered  his  incjuirles,  he  had  in  hie  po««eB* 
ttioQ  noteH  of  a  few  ca«e8  of  cancer  in  which  after  u  lapse 


178 


Vaginal  HYsrERHCTouv. 


of  five  years — in  one  case  of  thirteen  years — tliere  hatl  been 
no  returu  oi  the  disease.  These  were  cases  of  ciincer 
affecting  the  breast,  the  lip,  and  other  regions  of  the  body; 
but  he  contfindcd  that  ths  carability  of  the  disease  by 
extirpatioD  when  it  had  attacked  soms  parts  of  the  body 
having  been  established,  there  was  no  reason  why  cancer 
of  the  oterus  should  not  also  be  auccesafiilly  dealt  with  by 
surgical  operations.  The  only  difficnlty  to  be  eaconutered 
iu  cancer  of  the  cernx  uteri  was  the  peculiar  anatomical 
snrroundings  of  the  locality  under  oonaideratioD.  He 
agreed  with  Dr.  Playfair,  who  had  said  that  only  a  bold 
lann  could  always  venture  to  diatinguish  confidently  be- 
tween cancer  of  the  cervix  and  other  non-malignant  con- 
ditions which  ao  closely  simulated  it.  Here  he  would  ob- 
serve parenthetically  that,  upon  the  authority  of  Dr.  Play  fair 
and  of  Dr.  Bury,  an  uadoubied  case  of  uterine  cancer  has 
been  reported  cured  by  Chian  turpentine  mixture.  Some 
speakers  had  commented  upon  the  tendency  of  uterine 
cancer  bo  spread  laterally  into  the  parametrium  rather 
than  towards  the  fundus  ut©rij  and  had  urged  the  useless- 
neas  of  removing  the  fundus  as  well  aa  the  cervix.  Mr. 
Jennings  accepted  the  statement  as  to  (he  usual  invasion 
of  the  parametrium  in  a  lateral  direction,  but  not  the  in- 
fer«uca  as  to  treatment  drawn  therefrotu.  He  maintained 
that  the  entire  organ  should  he  first  removed,  and  the 
surgeon's  hand  suhaeque^ntly  inserted  into  the  pelvic  cwvity, 
by  which  means  diseased  portions  of  the  parametrium  and 
the  ovaries  could  bo  drawu  downward  and  removed.  He 
was  the  first  surgeon  in  this  country  who  had  success- 
fully employed  forceps  to  arrest  the  hemorrhage  from  the 
broad  ligaments  iustcad  uf  ligatures.  Inao  doing  he  bad 
adopted  the  suggestion  of  Sir  Spencer  Weils  More  than 
u  year  ago  he  treated  a  case  of  epithelioma  situated  at  the 
orifice  of  a  hypertrophically  elongated  cervix  by  amputation 
sufficiently  higU  up  to  ensure  tlie  incisions  passing  tbroagh 
perfectly  healthy  lisaues.  Such  a  case  was,  however,  rare, 
and,  as  a  general  rule,  Mr.  Jenuiags  advocated  total  ex- 
cision of  the  uterus  after  the  method  he  had  described. 


VAOINAL    UYSTKIueC'tOHT. 


179 


Dr,  GuiPriTii  here  imiuiriug  wimtlier  ia  the  oaao  Mr. 
JtinoiugH  bad  just  referrod  to,  the  diagiiuHiH  was  confirmed 
by  microscopic  examinatiouj  Mr.  Jenuinga  replied  in  tbe 
negative,  but  aaid  that  tlie  diagnosis  rested  upon  the 
authority  o£  four  surgeouis. 


Dr.  CuLLiNOWQBTH,  in  reply,  expresaed  the  pleaanre  it 
gavo  liim  to  see  Dr.  Graily  Hewitt  in  the  chair  on.  that 
occasion,  Dr.  Uewitt  hariug  been  on&  of  the  only  two 
speakers  who,  when  the  subject  of  total  extirpation  of  the 
uterus  for  cancor  was  discusaed  by  the  Society  in  1886, 
had  cofvaiued  from  deuouuciiig  the  operation  as  unjustifi- 
able. Dr.  John  Williams  had  nrgned  that  the  statistics 
of  the  Geroian  operators  were  umeliable  on  the  ground 
that,  in  Germany,  ragiual  hysterectomy  was  performed  not 
only  for  cancer,  but  for  other  conditions.  This  would 
have  been  a  sound  argument  if  the  German  operators  had 
beon  in  the  habit  of  mixing  the  cases  in  their  reports. 
But  it  was  not  so.  The  statistics  of  tbe  cancer  caaea  wore 
given  separately.  Let  them  take,  for  example,  Mtiach- 
meyoHfl  cases.  Of  the  total  number  reported  (ItiO),  eighty 
were  cases  of  cancer.  Only  four  out  of  the  eighty  patiouta 
died  from  the  operation,  a  mortality  of  exactly  5  percent. 
Tbe  total  mortality  amongiit  the  whole  160  cases  was  5'4 
per  cent.,  so  that  at  Dresden  the  operation  was  slightly 
less  fatal  in  the  cases  of  cancer,  than  when  performed  for 
less  fierious  conditions.  Dr.  Williams's  next  point  was  that 
he  could  not  accept  the  statement  as  to  the  disease  having 
infiltrated  the  tissues  above  the  oa  internwrn-,  becauBe  of 
the  difficulty  of  deciding  tbe  precise  lino  whore  cervw  ended 
and  corpiu  began.  He  thought  this  was  a  somewhat 
poor  argument  to  bring  forward,  for  if  the  inOltration  had 
esteudcd  so  near  to  the  vs  internum  as  to  raise  a  doubt 
whether  it  had  or  had  not  passed  the  line,  surely  the 
point  for  which  he  (Dr.  CulUogworth)  was  contending 
might  be  conceded.  As  a  matter  of  fact,  however,  in 
three  oat.  of  the  four  specimeus  there  waa  no  manner  of 
doubt  as  tu  tho  position  of  the  oa  internum;   it  was  reo- 


180 


VJLQINAL    aYeil'KElKCTOHT. 


dered  ovidunL  hy  Uio  uwhbI  constriction,  ne  well  as  nscer- 
lutuvd  by  uL-vumtti  tuesisuruiiiout ;  wbilo  in  tho  Funrtb  cuko 
it  ImJ  tu  be  tietermiiiud  hy  mt-'iuiu i-uiUE'iit  alono,  tlie  glands, 
Dpon  wbicb  Dr.  Williiims  thuugbt  the  deter  mi  nut  ion  sliouM 
entirely  real,  were  too  tar  involved  iu  tUe  diseiijic  to  allowr  of 
tluiir  ideiitilicHtiou.  Di*.  Williaiiis  next  naid  thnt  no  bettor 
evidence  could  have  becu  udduced  in  faymir  of  liis  view 
timii  was  uit'ot'dcd  by  tbe  fivo  lauueuui-sptjcLmeus  on  tlie 
ta\}h.  Ho  muBt  say  tbat  lie  listened  to  that  ictiiuik  with 
aniHZt>mRnt.  Did  Dr.  Willintim  nn]y  ac-knowledge  tboso 
tissiiUH  to  1)0  (raiici-roii8  wliicli  liiul  bouunie  ulcornted  and 
doxtmyttd  ?  Siiivly  lie  wonld  itllow  tluit  thp  tiBsues  uften 
Wcame  iuCUrated  to  a  coiiNideniblt!  (list;ince  beyoud  tbe 
limits  uC  Lbo  dL-Htruclive  process.  Tlit-  L-laitu  tliat  tliesu 
specimens  disproved  the  tendency  of  tbe  disease  to  alTeut 
tlie  carpus  lUeri  could  uofc  ior  a  moinenl.  be  siistatned,  for 
iu  two  of  tbem  tho  InBItrntion  bad  exteiided  to  witbin  a 
quarter  ui  an  iiicli  of  the  fundus,  in  one  to  within  one- 
third  of  an  inch,  and  in  another  to  within  an  inch.  Again, 
iu  the  remaining'  spocitnen,  thougli  it  was  certain  that 
tho  uppBi"  ptirt  of  the  corpua  aa  well  asi  the  lower  had  be- 
come iuvaduU,  it  was  found  imposHiblo,  owing  to  the  age 
of  tha  prepiiratiini,  tu  defiiit;  the  limit  by  precise  inpasure- 
nient.  With  regard  to  tbu  recominuudaliori  that  the 
operator  should  be  guided  u»  to  the  extent  of  his  opera* 
tion  by  tbe  conditiouH  discovered  ict  tho  timo  of  operation, 
it  was  one  tliatj  though  it  Houndod  well  in  a  speech  aud 
looked  well  on  paper,  could  seldom  be  carried  into  pruc- 
tice.  [f  a  patholo^stj  la  the  quiob  of  bis  laboratory  and 
with  the  specimen  in  bis  hand,  hesitated  to  define  the 
limits  of  the  cancorons  infiltration  until  he  had  had  an 
opportunity  o£  submitting  it  to  cortaiu  proeeBsoB  of  hard- 
ening and  Htaiiiing,  and  of  exHUiiinng  it  iiudor  the  micro- 
Hcope,  how  waa  an  operator  in  the  midst  of  an  anxious  and 
difficult  operation  to  be  expected  to  decide  such  a  matter  t 
It  wait  often  quitu  impossible  for  liiui  to  do  so. 

Oue  of  Dr.   Williams's  arguments  iu  favour  of  tbe  ao- 
jcallud   minor  opcratiou   was   derived  from  the  fact  that 


I 


VAQINAt    HTBTBRKnOMT. 


181 


wTten  tlie  disease  recinred  after  high  ampntAtion  of  the 
cancerous  cervix  the  rccurrenco  gcaL-rally  took  place,  not 
in  the  uteritie  stump,  but  in  the  parametric  tissue.  This 
ntidouhtcdly  oonatitutod  a  more  dillicult  nrjrmQcnt  to  mnct 
than  thoso  that  had  liitlierto  boon  doalt  with.  The  pho- 
nomenon  had  its  analogue  in  tho  breast.  IF,  iu  the  ease 
of  a  CBUcerous  hroast,  a  snrgaon  contents  himself  with  ox- 
Ctmng  tho  difteased  portion  instead  of  removing  the  whole 
gland,  any  recurrence  that  vn&y  take  plaoe  does  so  in  tho 
Bkin,  or  gtanda,  or  other  eurroundirag  tisRUO,  rather  than 
iu  tho  stump  op  unromoved  portion  of  tho  breHst-gljiiid. 
It  was  a  curious  pathological  fact,  and  one  that  had  ao  far 
received  no  adL-quate  explanation.  But  the  knowledge 
of  this  fact  detem^d  few  eargeona  from  removing  the 
entire  brennt  in  cases  of  cancer;  ond,  as  a  matter  of  ox- 
periencp,  the  surgeons  who,  like  Dr.  Banks  of  Livorpoolj 
removed  it  most  freely  were  able  to  show  the  largest 
percentaipe  of  cures.  Moreover,  although  it  was  the  rule 
for  recurrent  nancer  of  the  ei:rviir  utKri  \o  attack  f>ther 
parta  tliftu  the  uterine  Htump,  this,  as  Dr.  Williams  him- 
self had  shown,  was  not  invariably  the  ease.  Was  it  not 
therefore  wiser  to  extirpate  the  eutire  organ  rallior  than 
run  tlio  risk  of  recurrence  in  the  ntump  ?  Dr.  Williams 
concladed  his  remarks  by  prophesying  that  a  recnrrrnre 
would  take  place  in  all  tho  cases  reported  iit  the  paper. 
It  was  highly  probable  that  that  prophecy  would  be  ful- 
filled. It  was  unfortunately  only  too  true  that  rccurrenco 
does  occur  after  tho  great  majority  of  operations  for  the 
removal  of  cancer,  in  whatever  part  of  the  body  thoy  are 
nndortaken,  eo  tliat  it  becamo  pretty  safe  to  foretell  ulti- 
mate  difmppoiutnieiit  iu  any  givon  tioriefi  of  three  or  four 
cases.  Mr.  HutlJn  had  shown  that  even  in  «o  nccesHihlR  a 
region  aa  the  bnnist  the  cures  after  operation  for  cancer 
do  not  exceed  lOto  15  per  cent. ;  and  if  that  were  true  of 
the  brenHfc,  where  the  part  could  be  freely  removed  and 
diBoaeed  glands  extirpated,  what  might  bo  expected  in 
the  caac  of  iiiternnl  urgaua  like  tho  ntcrus,  whoro  thu 
cooditiona  iroro  so  much  1i-»b  favourEUilc?      But  even  in 


182 


TAOnfAL    HTSTEBECTOMT. 


thia  matter  of  recurrence  the  operfttion  of  vaginal  liyste- 
rectomy  haJ  completely  jnstifieil  itself,  for  experience  had 
bIlowii  that  the  percentage  of  cares  was  actually  higher 
than  in  the  ca.se  o£  removal  of  the  breast.  Taking  the 
Dreeden  atatistics  for  example :  of  the  eighty  cases  of 
total  extirpation  for  canoerj  no  fewer  than  twenty-aeiren 
lad  lived  for  two  years  and  upwards  without  any  sign  of 
recuiTscoe,  and  therefore,  according  to  the  pule  Dp. 
'WilUamB  had  laid  down,  or  at  any  rate  had  accepted, 
might  be  prononnced  cured.  Granted,  however,  that  the 
chances  of  effecting  a  permanent  cure  were  comparatively 
small,  was  the  operation  therefore  to  be  abandoned  T 
Had  it  BO  temporary  value  even  in  those  cases  where  the 
disease  unfortunately  returned  and  the  patient  ultimately 
died  from  itf  Let  them  take  the  case  of  the  woman  Knight, 
the  first  of  the  short  series  which  formed  the  baaia  of 
the  paper.  When  the  patient  was  operated  upon  ehewas 
suffering  from  continuous  hfemorrhage  ;  her  life  was  a 
burden;  she  was  thin,  careworn,  wretched,  and  unable  to 
attend  to  her  household  duties.  It  was  now  fourteen 
months  since  the  operation,  and  although  there  had  been 
signs  of  B  recurrence  of  the  growth  after  the  first  eight 
months,  and  a  permanent  cure  was  therefore  out  of  the 
question,  so  slowly  had  the  recurrent  disease  developed 
that  the  patient  had  even  up  to  the  present  time  been 
almOBt  entirely  free  from  hasmorrhage  j  there  had  been 
little  or  no  offensive  discharge  ;  and  she  had  been  enabled 
to  attend  to  her  household  duties  and  to  the  wants  of 
her  sick  husband.  Did  not  this  repay  her  for  the  opera- 
tion ?  Did  not  the  comfort  she  had  gained  during  these 
fourteen  mouths  compensate  for  the  risk  T  The  value  of 
an  operation  was  not  to  he  measured  merely  by  the  chance 
of  its  effecting  a  permanent  cure. 

He  now  turned  to  the  remarks  of  Dr.  William  Duncan. 
Dr.  W.  Duncan  commenced  by  expressing  his  want  of 
foith  in  German  atatistics.  The  questions  that  had  been 
raised  could  only  be  settled  by  statistics;  and  as  wo  must 
have  them,  ho  had,  in  his  paper,  quoted  the  moat  recent 


I 


TAQINAL   HTSTERICTOMT, 


183 


stAtiakica  of  two  op  three  operators  who  had  had  a  very 
large  experience.  Those  operators  happened  to  he  Germans. 
Surely  the  figures  were  not  on  that  account  to  he  pnt 
lightly  aside  as  unworthy  of  Credence.  Anticipating,  how- 
ever.Bome  such  objection  as  that  raised  by  Dr.  W.  Duncan, 
ho  h&d  been  cfireful  to  select  amongst  the  many  aene&  of 
fitfttistics  available  two  sets  of  cases  only,  where  opera- 
tions had  been  performed  by  iQeo  well  known  to  the  en- 
tire profeesiou  as  eminently  trustworthy  and  honourable, 
viz.  Leopold  (by  whom  many,  if  not  indeed  most,  of  the 
operations  reported  by  Miinchraeyerhad  been  performed], 
Mnnchmeyer  himself^  and  Xaltenbach.  The  statistics  of 
these  men  were  beyond  cavil.  He  had  quoted  them,  not 
because  he  shared  Dr.  W.  Duncan's  diatrnBt  of  German 
statistics  in  genei-al,  but  because  he  desired  to  deal  with 
figures  that  every  Knglish  gynsocologist  would  accept. 
Dr.  W.  Duncan  went  on  to  say  that  the  museum-spcci- 
meufi  he  had  placed  on  the  table  were  valueless,  because 
in  each  of  thoui  the  diHease  had  advanced  to  a  stage  when 
no  one  would  think  of  operating.  His  answer  to  that 
was  that  the  specimenB,  as  Dr.  Duncan  most  know  very 
well,  were  brought  forward  with  a  definite  object,  wholly 
uuoonnected  with  the  qaesfcion  of  operation.  They  were 
produced  to  show  that  cancer  of  the  cervix,  of  both  kinds, 
if  allowed  to  run  ile  natural  course,  nltiuiately  invaded 
tbo  body  of  the  ntenis.  All  the  five  specimens  had  beeu 
taken  out  of  tbo  jars  by  Mr.  Shattock,  aod  sectioos  cut 
from  them  had  been  submitted  to  a  prolonged  and  careful 
mioroBcopical  oxaminatiou  to  determine  the  particular 
nature  of  the  growth  in  each  case.  The  result  whs  re- 
markable, in  that  it  showed  that  of  the  four  epecimeus 
in  which  the  chauges  effected  by  maceration  still  per- 
mitted a  diagnosis  to  be  made,  three  were  examples  of 
squamouB-celled  carcinoma,  and  only  one  of  columnar- 
celled  or  glandular  carcinoma.  Bo  that  we  had  here  three 
instances  of  the  ultimate  inflltrattoa  of  the  corpus  ulerif 
to  within  a  very  short  distance  of  the  fundus,  by  that  form 
of  cancer  which  was  considered  even  less  prone  than  the 


184 


TiaiKAL  BTSTESKCtOltT. 


Other  to  extend  in  t\td  direction.  With  re^rd  to  the 
condition  of  the  utero-sacral  li)^nicDts,aad  Dr.  W.  Daucan's 
qnc«tion  *a  to  irhcthC'r  this  had  been  a!>ecrtninod,  he  begged 
%n  refop  to  tho  reports  of  the  caws  thcmsolvea.  Tn  two 
coflos  it*wau  known  before  tho  opcrBCion  that  the  ntero- 
iwcral  h'gaments  were  involved  in  adhesions,  bnt  those 
adhRHianH  were  of  an  inflaintnatory  nature,  and  though  thejr 
added  greatly  to  the  difficultjr  of  the  operation  (hey  were 
Dot  considered  as  contTn-indicattoon  to  it.  The  state  of 
the  nten>sacral  ligaments  was  not  the  lent  aa  to  the  pro- 
priety  of  opentting.  Fiaatly,  Dr.  W.  Duncan  exprepsed 
bis  bfltef  that  in  cancer  of  the  cervix  the  disea&c  did  n<4 
spread  into  the  body  of  the  nt^ms.  Expreasiona  of  belief, 
liovrever,  did  not  cnnstitnte  an  argument.  Dr.  Duncan 
mnat  produce  ovidcnco  iu  support  of  his  belief  beforo  hia 
opinion  eould  be  sccopted  b»  of  any  value.  Ho  had  not 
done  tliiBj  neither  had  he  given  any  good  reaKon  for  not 
accepting  tho  evidence  that  had  been  adduced  in  itnpport 
of  the  contention  of  the  paper. 

With  the  opinion  expressed  by  Dr.  Sinclair  that,  as 
regards  their  difficulty,  there  vra.>4  scarcely  anything  to 
ofaooM  between  the  two  opemtiona  of  total  extirpation  and 
«apr»-Taginal  ampliation  of  tho  cervix,  he  entirely  (^reod. 
Up,  Sinclair  pToforrcd  socuring  tho  broad  ligaments  by 
ligature  to  using  tho  elamp  forceps  for  that  purpose.  The 
points  in  favour  of  tho  clamp  seemed  to  him  {Dr.  Culling- 
worth)  to  1)0  (1)  tho  great  waving  of  timo,  amounting  pro- 
bably to  twenty  minntcs,  which  was  a.  not  unimportant  con- 
sidct-aLlon  in  an  operation  of  thi»  kind  ;  and  (2)  the  larger 
extent  of  the  slough  in  the  parametric  connective  tissuo 
ant«ilcd  by  its  use,  which  was  n  distinct  advantage  whore 
this  tisHue  was  beginning  to  be  iriYndctl  by  the  di-ieane. 

The  romarkfl  of  tho  other  spcakcrfl  had  in  a  grt'at  mea- 
SBre  been  replied  to  in  the  preceding  obaer^'ationfl,  and  his 
fnrther  cwramentH  njion  thorn  would  accordingly  be  very 
brief.  Dr.  LewL-rM  had  Hpoken  of  the  danger  of  total  ex- 
tirpation as  compared  with  Hupra- vaginal  amputation, owing 
to  the  nocossity  for  opening  intji  the  peritoneal  cavity  in 


rAOIHAL   HTSTZRECmMT. 


nh 


the  former  opei'ation.  It  was,  however,  by  no  means 
uncoinmoii  for  an  opnning  to  be  accidentally  made  iiitu 
Douglas's  pouch  in  sapra-vagiaal  amputation.  Wlieu  tliat 
accident  occurred  it  was  treated  by  the  advocates  of  supra- 
vaginal amputation  as  a  matter  of  Httle  importnnco.  If 
tlie  opening  of  tho  porituneum  countituted  an  element  of 
danger  in  the  one  operation  anrely  it  did  ^o  in  the  other.  To 
his  mind  there  was  much  leHS  danger  in  opening  the  peri- 
tooeal  cavity  where  this  was  followed  by  free  drainage,  as 
in  the  caae  of  total  extirpation,  than  where  the  peritoneal 
wound  was  covered  up,  as  in  the  case  of  such  a  wound 
being  made  daring  sopra-vaginal  aiiiputnliou  of  tbec«rWx. 
An  instance  was  given  whore  a  batton-holo  opening,  acci- 
dentally made  in  the  poritoneum  of  DoiiglaB's  pouch,  dur- 
ing the  operation  of  xupra-vaginal  nmputAtiou  of  the  cervix, 
had  led  to  a  fatal  result.  The  time  had  gone  by  for  dread- 
ing the  peritoneum,  and  he  could  not  admit  that  the  free 
opening  of  the  puritoneni  cavity  added  to  the  dangers  of 
total  extirpation.  Dr.  Lowers,  in  coinpariugthe  mortality  of 
the  two  operatioDH,  bad  quotod  figures  that  wito  ultogetbor 
incorruct.  The  mortality  front  Bupra-vnginal  amputation, 
80  far  from  being  nil,  wae,  at  present,  over  7  per  ceot., 
even  in  the  hands  of  the  most  able  oper&toni ;  while,  on 
the  other  band,  the  prt*Beiit  mortality  from  total  extirpa- 
tion was  not  20  per  oeut.,  but  5  per  cent.  Dr.  Lewers  had 
risen  to  explain  that  the  mortality  of  nil  in  supra-vaginal 
amputation  was  taken  from  his  own  Heriea  of  cases.  In 
that  case  he  shonld  have  said  so.  He  ought  also  to  have 
told  them  how  he  arrived  at  his  estimate  of  the  mortality 
of  total  extirpation.  Perhaps  be  would  say  whether  he 
bad  taken  thai  alno  fi-om  his  own  experieaco. 

Br.  LtWKKS. — No,  my  own  death-rate  from  total  extir- 
pation ha«  boitn  abonl  iA)  per  cont. 

Dr.  CuLLiBiowoRTii.— Kvidcntly,  tlien,  the  compArison 
was  in  every  sense  unfair.  Dr.  Lewerit  was  of  opinion  that 
English  practice  fihould  be  guided  by  English  stnlistics. 
He  (Dr.  CnlUngworlh)  was  of  an  entirely  contrary  opinion. 
The  number  of  totibl  oxtirpattons  that  had  been  performed 

VOL.  XXXII.  1^ 


186 


VAOlKAt.    HyaTHBKCTOMT. 


in  England  was  vcrj  small  incomparisoti  witli  tte  iiumlter 
pert'ormcd  lu  otlier  countries,  and  it  would  be  ridiculous 
not  to  accept  the  tcnchin^a  of  larger  experience.  In  tlio 
case  of  otlier  operations  we  were  guided  ^bltnost  entirely 
by  the  experience  of  our  German  brethren.  Let  tUem 
take  for  example  ths  modern  Cjosnrefiu  section,  which  wo 
owed  to  Gorraaiiy  :  and  Popro's  oppratiun,  for  which  we 
were  entirely  indebtod  to  Ttalv".  NoItLer  of  thettB  opera- 
tions would  ever  have  been  performed  in  this  country  had 
English  operators  been  guided  by  KnglJsh  statiHtics. 
Operators  in  tliis  and  in  every  other  country  ought  to  he 
rendy  to  profit  by  tlie  results  of  others,  whatever  might  be 
their  nationality. 

Dr.  Hayes  had  laid  atrees  on  the  obligation  that  rested 
upon  118  of  putting  tho  chances  fairly  and  fully  before  a 
patient.  With  tbis  he  heartily  concurred.  Not  only 
shoulrl  tho  risk  of  an  immediately  fatal  reaiitt  b©  explained, 
but  the  strong  probability  of  recurrence. 

The  last  speaker,  Mr,  Jennings,  had  very  properly  said 
that  we  ought  not  to  limit  ourBcIvoa  to  one  operation  or 
one  method  of  treatmenti  but  to  be  rejidy  bu  adopt  one 
operation  iu  one  case  and  another  in  another.  He  (Dr. 
€ulling%'orth)  had  hinted  in  his  paper,  aud  he  might, 
perhaps,  with  advantage  have  given  the  suggestion  gi-eator 
prominence,  that  while  the  partial  operation  might  be 
RuSiciQut  in  motit  caues  of  fi(|uauoti8-ceI]Dd  carcinoma, 
total  e.xtirpation  was  the  only  Bate  method  of  dealing  with 
glandular  carcinoma  of  the  cervix.  If  that  view  proved 
to  be  correct,  and  the  evidence  at  present  available  cer- 
tainly »cemed  to  point  in  that  direction,  each  operation 
would  have  its  own  proper  sphere  of  uFiefulneas,  and  a 
mioroacopical  examination  of  a  portion  of  the  diseased 
tissue  would  decide  which  operation  was  called  for  iu  any 
given  case.  It  would  be  narrow  and  unscientific  to  main- 
tain  that  one  operation  was  alike  suitable  for  every  caeo. 
Dr.  Sinclair  bad  well  said,  in  a  paper  lately  published  in 
the  '  Practitioner,' that  until  some  berter  method  of  treat- 
ing cervical  cancer  had  been  devised,  the  very  hopeless* 


VAOINAL    HYSTBRECTOUT.  187 

iiess  of  these  cases  if  left  to  themselves  would  lead  men 
to  adopt  operative  measnres  for  their  relief.  What  we 
oQght,  then,  to  aim  at  was  to  discover  which  operatioQ 
produced  the  best  results,  and  for  what  class  of  cases  each 
operation  was  the  most  suitable.  The  paper  that  had  been 
read  was  intended  as  a  contribution  to  this  inquiry.  He 
thanked  the  Society  for  the  kind  manner  in  which  the 
communication  had  been  received,  and  for  the  interest 
that  had  been  shown  in  its  discussion. 


JUNE  4tb,   1890. 

AmxD  L.  Galadih,  M.D.,  President-,  in  the  Chair. 

Present — 43  Fellows  and  6  Visitors. 

Books  were  presented  hy  Dr.  Andrew  P.  Curnor,  Dr. 
Herman^  and  the  Royal  College  of  Surgeons  of  England. 

Augustiia  W.  Addinsell,  M.B.,  C.M.Edin. ;  and  Robert 
J.  Carter,  M.B.Lond.,  were  ndmitted  Fellows  of  tho 
Society. 

Hugh  Smith,  M.D.Lond.  (Bow),  was  declared  admitted. 

The  following  gentlemen  were  proposed  for  election  ; — 
Alfredo  AntnncB  Kanthack,  B.A.Lond,,  F.R.O.S. ;  and 
Prodoriok  John  McCnnn,  M.B.,  C.M.Edin. 


THE   GLANDS    OF   THE   FALLOPIAN    TUBE. 
By  J.  Bland  Sbttoit. 

Im  1888  I  plocod  before  thia  Society  evidence  and  argn- 
mcnt  to  snpport  my  opinion  that  the  familiar  rngie  of  tho 
raucous  membrane  lining  tho  FatlopiaQ  tubes  are  in 
eesonoe  glands.  On  that  oxjcaeion  it  was  urged  by  one 
Fellow  (Mr.  Alban  Doran),  a  capable  critic,  that  1  ought 
to  have  supported  my  argument  by  adducing  evidence  in 
the  shape  of  accurate  drawings  ittustratiog  the  characters 
of  thesti  glands  iu  iho  Fallopian  tubes  of  other  mammals. 

VOL.  IXZII.  14 


mo  TBB   OtASne   OF  TBE   PALt.OPrAK   TOBB. 

As  time  and  opportuuit;  pcrmittod,  I  bnro  bad  some 
feitbfal  sketches  prepared,  by  a  competent  drftnghteraan, 
from  eectious  made  under  ray  personal  auperiuteiidenco  by 
Mr.  Kennetb  Lawson  and  tlie  Bkilful assistant  to  tbe  museum 
of  the  Middleeei  Hospital  (Mr.  Pollard). 

The  specimoDB  shown  as  types  were  taken  from  the  Fal- 
lopian tube  of  a  Macaque  MonVey,  Mncncus  rke»uj»,  and  the 
Panolian  Deer,  Gervm  eltti. 


FlO.  1 .— 'Tnin«verie  Miction   tlirougb  tie  Fiillopian  tnlHi   of    a. 
Mncnquc  Monkey,  M.  rhvmt,  to  >bou-  tU»  glunil-clmtcn. 

The  nteniB  of  a  Ma«a(]iiB  may  be  best  doHCribcd  as  n 
rainiatni'o  hnman  uteru.':.  A  tmnsverse  section  taken  from 
the  middle  of  its  tiibo  is  shown  in  Fig.  I. 

This  specimen  shows  vei-y  well  the  cluater-like  arrange- 
ment of  the  glandular  acini,  each  presenting  a  single  layer 
of  large,  regular  sub-coluiunar  epithelium. 

Au  oxamination  of  a  large  number  of  Fallopian  tubes 
shows  Unit  the  middle  of  the  tube — that  is,  near  the  junc- 


192 


THE    (irJNDS    OP    THE    FALLOPIAN    TDHE. 


ap'Sciraen,  sliowing  mi  isolatod  gland  from  the  Fallopian 
tube  of  the  Panotian  Deer,  Ceri-vjt  eldi,  is  sketched  in 
Fig.  2.  It  is  upon  the  type  of  a  compound  racemose 
gland  with  a  single  layer  of  large  regular  columnar  epi- 
thelium. These  conipJex  recesses  extend  around  the  whole 
Ctrcnuiference  of  ttie  tube,  and,  as  a  rule,  eight  to  twelve 
maj  be  counted  in  a  single  section.      It  is  possible  that 


^•L^^ 


CAVITV 
OF  CY9T 


„*U>?* 


Pia.  a. — Mici'utMpical    cliBTacl^rH    of    «     E^llopian    ndenoina 
(Dornn'a  caae),  tor  nitn]iariBan  with  Ftg.  1. 


the  epithelium  oE  these  recesses  is  furnitihed  with  cilia,  bnt 
it  is  not  so  ensy  to  determine  this  paint,  atthongh  it  niikj 
seem  n  simple  matter  to  those  nut  experienced  in  practical 


THE   eUNDB  OF  TBB  FALLOFUK   TUBS.  193 

hiatology.  These  facts  are  of  interest  in  relation  to  adeao- 
mata  ot  the  Fallopian  tube.  The  first  specimen  of  this 
apparently  rare  form  of  tumour  was  described  by  Mr.  Alban 
Dornn  as  a  papilloma  of  the  tube.  I  Lave  had  au  opportunity 
of  re-esa.niiniiig  this  tiimonr  microacapically,  and  find  it  to 
be  an  adeiioum,  and  the  glaud-strurln  i-u  miuiics  that  of  the 
normal  gliuide  of  tho  tube.  A  sketch  of  the  inioutt  struc- 
ture of  this  tumour  is  gi7eu  in  Fig.  3,  Eor  sug-geKtisc  cum- 
pari&ou  with  Fig.  1  Eroui  the  Macaque. 

It  may  &oom  to  mauy  that  the  glandular  nature 
of  these  receesea  is  merely  n  question  of  interpretatiouj 
and  not  so  much  s,  qut^stiou  of  fact ;  it  is  neverttieleBB 
a  matter  of  sume  importance  in  dealing  with  the  patho- 
logy of  the  Fallopian  tube.  In  toncludiug  this  brief 
com  muni  cation  I  Hubmit  thut  these  recesses  in  the  tube  are 
as  thoroughly  glandular  in  their  nature,  arise  upon  pre- 
cisely tlie  same  plan,  and  at  the  same  period  as  those 
roucsseti  of  the  uterine  utucoua  membrane  to  which  all  of 
UK,  withuut  any  quostioa,  upply  the  term  glauda. 

Dr.  Walteb  GBrFFiTH  wan  plad  to  find  that  Mr.  Suttou  hod, 
by  his  cominuutca.tion  that  evening,  acknowledged  the  nix-eaaity 
for  the  study  of  the  oviducts  of  vertebrates  as  an  important  stage 
in  the  investigation  of  the  |ir<>g«nGe  of  glands  in  the  human 
FiUiopiaii  tube.  Mr.  SJuttoii  musU  however,  first  licfint  what 
hi;  mimiit  by  a  ghind.  imd,  as  Iiadbi-en  !iiigge«ted  to  Dr.  Griffith 
by  an  nUIe  biBlologiat,  bv  B]it>uld  make  longitudiiuil  aa  well  as 
traiiHwrBc  sectiouti  vf  the  tubu  to  yaove  ibiu  puiut.  AVbat  aj}- 
nmrt'd  to  hv  glauda  iu  trausvL-rBe  sectiou  were  siuiply  lougitii- 
dinal  folda. 

Ur,  Ueywood  Suitu  said  that  the-  point  brought  forwuj-d  by 
Mr.  Itlaiid  Button  vta  of  the  utniont  iiuportancet  not  ouly  from 
lhi.>  patholu^'itul  l>u1  nliu)  tlin  pliyitiologinal  point  of  viow.  It 
ti-ndcd  to  throw  light  upon  tho  localUattoii  ot  the  ovnm  iu  tiinos 
of  ectopic  gestation.  It  helped  to  dciuoustratv  that  thu  oviduct 
tMiug.  like  the  uterine  tiEsue.  furnished  with  glaudH.  wiut  the 
rcul  iiidilB  of  the  oTum  in  siifh  cases.  Lastly,  it  indicated  that 
su-cdled  abdouiuul  pregu;iucy  bcgau  invariably  as  tubal  preg- 
nancy, and  by  rupture  became  abduniiual. 

Mr.  ALUA.K  DoKAN  had  frequeutly  referred  to  hie  remarkable 
ciuf  of  (lapilloiua  of  the  tube,  which  was  published  in  the 
'  TraaHActions  of  the  Pathological  Society  '  for  1880.     It  provtdd 


IM 


apopuh:tic  ormt. 


tlul  Becretiotts  from  the  tutju  iasuiug  tioxn  a  pstuluiw  ostium 
might CMlMhjdru-puhtoiiL'um.  A  tuutaoiruu  "  Tfao  IU>Iatiou  of 
Hydro-prntoncun  to  Tabal  Diseaw."  bowdoa  this  (act.  -wiu  pub- 
luibvU  ID  the  '  TnnaairtiotM  of  the  Obetetrica]  Society '  for  1886. 
He  abundant  secretion  indicatHl  glands.  Mr.  Dorun,  howerer. 
deecribed  the  disease  as  "  jNi[>illoaia,"  because  be  coDsidered  it 
bomologoiu  to  the  warts  skxu  arouud  tbt;  labia  tu  ciisca  of 
chroilic  gouorrboi-a.  lo  bolb  catK's  tbe  pa^itkr^  masses  uiipvarud 
to  be  not  KO  niuvb  tuoioure  as  bjpertrophy  of  uonnol  IJMue  pro- 
diK'od  bv  cbronic  inflatntDatioD. 

Hr.  Blasd  Scrrox,  in  replv  to  Dr.  Griffith's  remarka,  said 
be  had  not  sbiftMl  ground  or  retranted  one  single  jioint  from  his 
prcTioiiA  (^ominnnic»tion  on  "  The  Cllande  of  tbe  Fallopian  Tubes  " 
oi  the  Sociely'tt '  Tran«aetionH  *  (vol.  xsi.  p.  i07j.  Dr.  Griffith  at 
that  ttiiiuurf^-d  that  thm'rideQcefurulBLedbj  the  oviducts  in  the 
Anphibia,  Ibu  Shark,  CAiffljrra,  the  Frog,  tb»TortoiaL-,Jtc.,  should 
be  Donsidered.  The  oriducts,  Mr.  S>ittou.  said,  in  these  forms  axv 
in  not  a  few  inatancea  richly  glandular ;  but  maitY  vearsi  of  obser- 
vation among  tho  Ii^bthyopaida  had  convinced  him  thatatiy  mor- 
pbvloi^iail  thi.-ory  could  be  proved  bjr  rvfcrt'uce  to  aucb  low  and 
potoutiai  funiiH.  Tbt-  (|iit^«tton  nf  tiic  gUudular  nalurx;  of  the 
Falluiiiiin  tubes  in  the  humau  female  (which,  by  ibe  way.  were 
Dot  highly  Bpeciali»ed  parts,  a«  Dr.  UritBth  believed)  niuil  )>e 
■ettled  by  obtterrations  of  the  parts  iu  Mammals.  The  grealvst 
difficulty  lay  in  the  fact  that  mauy  bt-lier*^  uiurv  teiiatriously 
«hat  they  were  taught  than  trusted  to  the  evidcructi  of  their  own 
seosefl)  and  it  was  waate  of  time  to  argue  with  such  extremely 
couservative  minds.  Comparative  anatomy,  embryology,  and 
physiology  indicated  moat  eniiiliiil  iwilly  that  the  recessoa  of  thu 
Fulopilui  tube  were  not  mere  foUiiigs  uf  tliv  tubal  uiucuu^t  mem- 
tnane.  but  gUoda.  Dr.  Griffith  also  asked  for  a  dL'fiuitioii  of 
a  gland.  This  detinitiou  was  fumistied  in  tbe  *  TransuctiaD»,' 
Tol.  XXX,  p,  *21t).  Uuc«  6,  i>,  lU.  11,  uud  12. 


APOPLECTIC    OVUM. 
By    Ajiakd    Rovtb,    M.O. 

Dk.  Auakd  Rocto  showed  a  recent  5p*jciinon  of  apopleiy' 
uf  the  dccidua,  from  a  Riultipara  aged  42.      She  Lad  borne 
three  childreD,  the  lost  five  years  ago,  and  had  pusaud  two 
"  fle»ihy  molee  "  since  ttieu. 

Wheu  under  Or.  Routh's  care,  in  Jauuai-y,  lS90,  she  bad 


UTKKDa   AND   ADHBRBNT    PLACBNrA. 


106 


sufTered  froii]  Uvo  slight  lia3moiTlia.gi;a,  pvecoded  by  three 
muullm'  fiiuenorrluBft.  The  uterus  was  eiilargod  to  the 
aiise  usually  altainetl  at  tite  third  mouth  of  g^statiou,  but 
felt  hard,  aud  there  waa  no  appreciable  comproseibility  of 
itB  lower  scgmcot. 

The  patioiit  wits  ordorad  to  use  iodised  vag-inal  douches, 
and  lu  report  sLuuld  auy  LajiuoiTbago  oi-  paiu  oucur.  For 
tho  following  four  luoutlis  sho  wan  regular,  iiud  ihuu 
passed  thiit  "mole,"  accoitipauied  hy  much  btemorrhago. 
Tilt?  ovniii  bad  died  nbout  thu  third  week,  and  the  dcciduik 
had  xemaiued  quiescent  til]  tbe  seventh  month. 


UTEKLTS  AND  ADHERENT  PLACENTA  FKOM 
PATIENT  DYING  OF  I'Ui^T-rAItTUM  H.«MOR- 
RUAGE. 

By  John  PoiLUfs,  M.D. 

Tub  patiout,  aged  87,  with  three  liviug  childreu,  waa 
delivered  by  craniotomy  ii  year  ago  iu  coiia«quenuc  of  a 
large  fibroid  in  iLe  ant-erioi-  wall  blookiug  up  the  pnlviis. 
Dr.  Phillipa  measured  the  size  of  tho  tumour  immediately 
after  labour  (the  index  Soger  being  passed  into  the  uterus), 
aud  it  was  apparently  of  tho  size  of  a  cocoanut.  She  was 
warned  if  proguoiicy  again  occurred  to  keep  herself  under 
obiwrvation.  This  iilia  failed  to  do^  and  ber  medical 
attendant  vms  CBllcd  iu  haste  to  find  her  moribund  from 
hffiiuorrhage,  a  full-time  living  child  born,  and  tlie  pla- 
centa closely  adherent  to  tho  uterine  wall.  As  much  uii 
po»siblo  wa8  removed,  but  she  died  from  tlie  excessive  post* 
partuiQ  haiuorrhage  within  au  hour. 

The  post-mortem  showed  tho  uterus  large,  tiabby,  and 
extremely  blunched.  The  rctBaine  of  the  placenta,  which 
was  )iituat(>d  ovortlio  site  of  the  previeualy  existiug  Sbroid, 
were  intimately  adhureul  tu  the  uterine  wall ;  this  was 
much  thickened  iu  that  position,  but  no  further  ti-aeo  of 
tho  previously  existing  tumour  could  be  discovered.      A 


196 


FUBDLEMT    SENlLll    ENDOMUTlMTm. 


small  iutra<miira1  fibroid  was  found  in  the  poeterior  uterine 

Wttll. 

Dr.  Piiillips  thought  that  the  fihroid  had  uudorgouu 
absorption  after  the  inatruineutal  labour,  Hntl  hod  not 
become  hypcrtrophied  with  the  conacijucut  preguaooy ; 
indeed,  that  appoared  to  be  the  only  explanation  of  the 
uuuBUal  course  of  things  in  this  case. 


SPECIMENS    FllOM  A   CASE   OP    PURULENT 
SENILE    ENDOMBTIUTIS. 


By  Gr.  B.  Hbbman,  M.B.Loud.,  F.B.C.P. 

Db.  Hbrhlun  exhibited  specimens  from  a  caae  having 
tbe  following  clinical  history  {from  notes  by  Mr.  P.  A. 
Qbiheh,  Clinical  Clerk).  A.  H — ,  aged  *Jo,  sailor's  wife. 
No  family  history  of  cancer  or  tumours.  One  sister  was 
iiaid  to  have  died  from  "change  of  lifoj"  licr  father 
diedj  aged  72j  from  "  paralysis  j"  her  raothor,  aged  50, 
from  "  dropay ;"  a  brotlicr  lived  to  65. 

Patient  was  always  regular,  except  during  [irugnaucy 
and  lactation,  till  the  age  of  fifty.  She  wus  married  when 
aged  twentyj  and  had  nine  children,  the  last  twenty-six 
years  ago,  She  had  never  been  q^uitewcll  Bince  uicuatrua- 
tioii  ceased;  had  suffered  from  rheumatism,  bronchitia, 
indigestion,  giddiness,  and  liendnebL-s. 

lu  June,  18Wf,  she  began  to  have  a.  discharge,  at  tiret 
whitish,  then  mixed  with  blood,  and  fi-om  the  beginning 
otrensive.  This  diiJclmrgo  lionceforth  continued.  At  the 
tioie  it  began  vhv  bad  mucli  pain  in  the  lower  abdomen. 
iShe  went  to  a  hospital,  took  some  medicine,  and  the  jmiti 
diminished.  For  the  last  six  months  she  had  beeu  loning 
tiesh. 

The  patient  was  admitted  into  the  London  Ht>K}>tta.l, 
under  tbe  care  of  Dr.  Herman,  January  13lhj  l&W.  Klie 
was  strongly  built,  rather  spare,  and  eomewhat  ausBinic. 


PDRtTI.BIKT    SENILE    EMDOUGTRITIB. 


197 


She  complained  (besides  the  discharge  and  hDomorrhagc 
elroady  mentioned)  of  pain  in  the  lower  ahdomen  and 
back,  and  cough,  which  prevented  her  from  sleeping.  Her 
appetite  was  bad,  and  the  bowels  were  confined. 

Bronchial  niieg  were  heard  over  the  chest,  but  there 
were  uo  other  tiigus  of  lung  disease.  No  cardiac  luurmur 
could  be  heard.  There  was  no  ubdumiiial  swelling  nor 
tendorucas,  nor  any  urinary  trouble.  The  urine  coutuinBd 
no  albomcu.  On  digital  examination,  the  vngiual  portion 
was  found  atrophied,  the  va^-iua  smooth  and  contracted 
Bt  its  upper  part.  The  corns  uteri  was  moveable.  With 
the  speculum  the  vaginawaa  fuund  injected, easily  bleeding, 
and  presenting  sjjots  and  patchesaf  livid  redne58,PHpecially 
at  the  upper  part.  The  cervix  nteri  was  small,  dark  rod, 
and  finely  granular. 

January  23rd. — The  pattent  was  examined  under  unu98- 
thesiu.  The  uterus  was  found  nioveable,  the  body  some- 
what enlarged  and  more  globular  than  usual ;  normal  in 
poaitiou ;  no  Uczion. 

The  cervical  canal  was  dilated  with  Ucg&r'ii  dilators  up 
to  No.  10,  at  which  point  the  rigidity  of  the  cervii  pro- 
ventfjd  the  dilatation  from  being  carried  further.  As  the 
canal  was  opened  up,  thick,  greyish-yellow  pus  poured 
from  it. 

Looking  at  the  history  of  discharge,  pain,  htemorrhago^ 
and  wasting,  it  was  thought  very  probable  that  llie  dis- 
eauo  WHS  maliguaut.  Considering  also  the  opinion  held 
by  itome  very  omincnt  authorities,  that  the  purulent  ea- 
dometritis  of  elderly  women  tends  to  become  malignant, 
it  was  thought  that,  even  without  proof  that  tho  coiiditiou 
was  at  present  malignant,  the  removal  of  the  uterus  was 
tho  best  treatment.  This  operation  was  forthwith  done. 
The  broad  ligamimts  were  securud  with  PiSan's  hietuostatic 
forceps,  which  were  left  in  for  thirty  hours.  T\w  patient 
i-ocovered  without  any  had  symptom!*,  and  left  the  hospital 
quite  well  and  free  from  discharge  and  pain. 

The  characters  oE  the  uterua  wei-e  as  follows: — It 
was  8  inches  iu  length.     The  uterine  wall  was  {  v(  an 


198 


POHULBNT    9£N'ILE    KNDOMKTKITJS. 


inch  thick.  Its  innur  surface  wa&  evcrywhurB  muootb, 
except  that  it  preseaU'ii  a  small  [loijp  about  tho  size  of 
a  pea.  Sections  were  made  through  this  polyp  ani  the 
adjacent  surface  of  the  uterus,  which  Dr.  Hermau  ox- 
hibitcd.  The  section  of  the  polyp  was  nbout  ^  of  an  inch 
long  and  projected  abont  4  oi  an  iucli  into  the  uterine 
cavity.  Tho  adjoining  surface  of  the  uterus  was  infil- 
trated with  round  cells  bearing  Inrge  imclei.  The  tissue 
BO  formed  gmttiially  merged  into  the  suhjacont  inuscular 
tiijgue.  TIio  roiind-ccllt'd  infiltration  extended  roufi^hly 
ubout  gi„  of  nn  inch  deep.  In  it  were  Mumoroii»)  glands, 
most  of  which  had  been  cut  acroi^a,  but  somo  of  which 
were  cut  lengthways.  The  deepest  of  thcui  was  about 
■jij  of  an  inch  from  the  suifHce.  They  were  lined  with 
regular  columutir  epitheliain,  which  at  uo  poiut  showed 
any  tendency  to  change  its  clmracter.  There  wore  also 
voAfiels  opening  on  the  t^urface  of  the  mucoue  membrane. 
U'he  polyp  consisted  of  connective  tiaaue,  infiltrated  with 
round  cells,  though  not  so  closely  as  th&  mucous  mem- 
brane of  the  uterns.  In  the  meshes  of  the  connociivo 
tissue  wore  Tory  aumcrous  glands,  tho  cavities  of  which 
wore  in  size  from  a^  of  nn  incli  in  dinuioter  downwards. 
They  were  lined  with  regular  columnar  upithelium,  which 
nowliere  showed  any  tendency  to  change  its  character  ;  nor 
were  there  any  epitlioliul  ingrowths.  There  was  no  dis- 
ease of  the  muscular  tissue  of  the  uterua. 

Somewhat  similar  aperitnenR,  taken  from  ca^es  having 
a  similar  clinical  history,  had  been  exhibited  to  the  Society 
by  Dr.  Horrocks  and  Dr.  Galabin  ('  TmnBactions,'  vol.  sxix, 
pp.  298  and  300).  In  Dr.  Horroclcs's  case  the  question  of 
cancer  waw  mooted.  In  Dr.  Gn.labin's  the  uterus  was  re- 
moved because  it  was  thought  to  be  eaucor.  Another 
Kimilar  Hpeciuion  was  exhibited  by  Dr.  Matthews  Duncan 
('Trans.,'  vol.  xx),  p.  64).  In  this  ctise  tlie  disease  was 
regarded  us  uialignuut  uutil  a  micruBcojiiestl  examiuutioi] 
had  been  made. 

Thcae  were  the  only  deaeriptious,  so  far  as  Dr.  Herman 
waa  aware^  of  the  histology  of  lliie  conditiuu. 


199 


CAllCINUMA  OF  THE  OVAltY. 


By  C.  J.  CviLiNowoETH,  M.D.,  F.lt.C.?. 

Dit.  CoLLiMawoKTn  oxliibited  a  soft  tumonr  of  tlie  left 
ovary,  removed  by  ojjemtiun  (iiufoi-tiiu&lely  willi  a  fatal 
result),  from  a  siiigle  lady  agod  (11.  A  microscopic  st>c- 
tioii  wus  alsu  h!u)wu.  The  uterus  was  euuriimiisly  fiilar(jed 
frum  Hbroiil«,  iinJ  tlnj  ovnrbii  tuiuour  liiy  bciiiud  it,  deep 
it!  the  ptiWis.  A  point  uf  interest  in  the  epuciuieii  was 
lliat  the  growth  had  buret  through  the-  tuuica,  albu^inea, 
slitting'  that  structure!  and  forming  a  soft  mass  of  new 
growth  protruding*  through  tbo  ronb.  In  8pite  of  the 
enlarged  uterus,  the  patient  had  not  noliced  any  increase 
iu  the  size  of  tbo  abdomen  until  fuur  weeks  previoiiHly. 
At  the  operation  thirteen  pints  of  ascitic  fluid  were 
removed  ;  the  iitoriis  was  left  undisturbed.  It  seemed 
most  probable  that  the  ascites  was  the  result  uf  the  apou- 
tancous  rupture  of  the  investing  muubraue  of  the  di»caaed 
ovary,  and  the  coitseiiueiit  irritation  of  the  peritonoum. 

No  disease  was  obborved  in  the  peritoneum  or  in  any 
other  parts  than  those  mentioned.  The  symptoms  after 
operation  pointed  to  inte»tinal  obstruction;  unfortunately, 
uo  post-mortem  examination  was  obtained. 

Mr.  Shattock  experienced  great  diflficulty  in  ontting  a 
BGctiou,  on  aL'Couut  of  the  extreme  softness  of  the  growth. 
The  nucroscopB  showed  the  growth  to  be  a  rapidly-grow- 
ing ciircinooiH,  being  compo»ed  uhuoiit  entirely  of  cpithc- 
liam. 


UISSKCTION  OF  A  FfKTTS,  THE  SUB-IECT  OF 
UETROFLKXION,  KCTOPIA  \1SCEKUM,  liTC. ; 
WITH  HEMAHKS  ON  TUE  FREQUENT  ASSO- 
CIATION OF  THESE  ABNORMALITIES,  AND 
ITS  CAUSE. 

W.  K.  DiKiK,  M.U.,  B.S. 
oaamuo  VHraicuy  ro  otrr-MTiiKTB,  ckkjit  hoktubbr  ao«piTAt.| 

rKXUCIAX.  BOTAL  BtMttTXL  rOK  CHtU^SB]!  AXD   WOMXX. 

(Bcccivcd  Febnurj'  BlV,  1890.) 
{AbgiraH.) 

Tub  HfwdttiL'U  biul  Uwn  sbowu  iu  tts  reoeDt  condiUoa  at  a 
funner  mcetiag  of  tbe  Socielj  ('  Traaaiictioiis,*  vol.  xxii,  1889, 
p.  306),  whcD  the  points  worthy  of  notice  in  the  labour  were 
lQi;Utioac(l.  It  wait  uow  compK'U-ly  Ji»«c<;tuU  aa<i  iIcsLribed. 
Tbe  vril«r  voii«<l(*red  all  the  abDofm^lities  priniiLrilr  du«  t<j 
{ailiiru  in  dt-Ywlopmont  of  th«  biml«r  jjart  of  the  gut.  He 
detaileil  thviu,  awi  eiidcRvoiired  to  accoimt  for  each  of  them  as 
exanajilcfl  of  thi?  chain  of  ill  results  arising;  from  this  defecUrv 
devolopmeut.     Ho  vumo  tir  tbu  following  cnijcluBio&e  : 

Bi^troflcxinn  and  ectopia  vijicorutn  majand  do  occur  iadcpcud- 
ently.  [They  may  therefore  b«  assocJatod  and  yet  not  have  a 
cuiuinoii  aiu»e.] 

Tbe  only  way  apparent  in  which  a  common  cause  could  act  it 
that  dcBtnted  by  Buai-aa  and  Hurry  ('Olat.  Tnius.,'  vol,  xsvi), 
oamclyi  by  shoncningor  doing  away  with  the  iimbili<'a!<i>rd,  imd 
thus  keopinfj  the  ahdoiutual  Eurfuctf  of  tliH  fwlUK  applied  to  the 
uteriue  wall  and  placenta.  The  latttr,  by  its  close  appliuitiun. 
preventa  closure  of  the  abdun]cu,ki.-t;piii)f  ajmrt  tbt.'  ceutritielallj 
growing  udgva  o£  tbe  abdominal  walls. 

Tbia  common  caUHC  in  fuiiuro  in  developmoat  of  the  hinder 
pari  of  the  gut  aud  its  procetses. 


m 


noTtov  OF  A  rcrrs. 


201 


Hp  applied  this  theory  to  the  present  cane,  and  congidore^l  tho 
course  of  t>veutH  vvut  ax  followM  ; 

1.  Imperfect  development  of  bind  gut  and  therefore  of 
alloatoiH,  rosultioK  in  (it)  abiicncti  of  umbilical  cord,  and  (?)  of 
one  of  the  vsaseU  (umbitiml  artfriea)  uorma.lly  projeeted  on  tho 
iillaiitoiii ;  (i*^)  interference  with  oatflov  of  iirine,  probality  at 
nllantoic  end  of  iirftcrB.  producing  riglit  hydronephrosis  au<l 
nbaonco  ut'  K'ft  kidric-y  iiud  uruter. 

2.  Rosalting  from  (n),  close  application  of  auterior  surface 
of  f(Gtu8  to  pliifioiita  and  iit^riQe  wall,  causing — 

3.  (a)  RetrofleiioD,  with  its  efft^cts  on  the  spine  (meningocele 
and  spina  bi&du  occulta)  iit  the  point  of  fluiion  ;  (b)  prnaanre- 
cSecta  on  the  sid«  of  the  body  hold  in  couta.ct  with  pkctsuta  and 
uterine  wall;  and  {r)  failure  of  abdmniiml  wall  to  cloBC. 


Tba  sabject  of  tho  prcsoat  uoto  ie  a  fates  wliicli  I 
showed  in  its  roccnt  condition  at  the  November  meeting 
of  thU  Society.  1  then  briefly  monttoned  certain  mattcra 
of  intcrent  relating  to  tho  labour.  The  foetus  I  obaervod. 
was  a  twin  of  about  eight  monlhs,  born  of  a  3-para, 
witli  quite  an  ordinary  history.  It  Ilvoii  an  hour.  There 
was  no  cord^  but  tlio  placenta  was  appHetl  closely  to 
the  extruded  viscera.  It  was  said  that  there  vtrs  only 
one  amniotic  cavity,  bat  tliis  statomont  was  probably  a 
mistake,  and  the  plucuntfo  wcro,  I  waa  informed,  embedded 
in  a  common  amnion  half  an  inch  apart.  The  other  child 
was  &  female,  and  naturally  formed  ;  it  was  bom  first  and 
lired  for  a  few  days,  dying  of  asphyxia  from  no  canae 
that  conld  bo  detected  at  the  necropsy.  Tho  two  children 
woro  of  the  game  age. 

The  external  appcnrance  of  the  foetus  now  exhibited 
was  roughly  described.  Tt  wa«of  small  size  (or  the  period 
named,  even  couaidering  that  it  was  a  twin,  being  but 
18i  inches  long. 

Oencral  Appearatice. — Tho  head  appeared  rather  large, 
but  this  waa  due  to  diminishod  length  of  the  trunk  owing 
to  tho  retroflexion  of  the  pelvia,  which  was  ao  completo 
that  tho  pubos  WAS  found  a  quarter  of  an  inch  in  rear  of 


^ 


202 


UIMFCTIOK   OF   A    ?«TOe,   THB   8DBJECT   OP 


the  lower  end  of  the  coccyx.  There  was  also  con^idornble 
lateriflexion  to  the  right,  and  some  torsion  of  the  lower 
part  of  tho  trunk  to  tlie  left.  The  integntnents  orei*  the 
nbdominal  viscera  were  entirely  absent.  The  anterior 
boundary  of  this  region  had  been  formed  by  amnion  and 
placenta,  as  stated  by  the  midwife.  The  heart  and  part 
of  the  left  lung  were  visible  outside  the  thorax,  th&  dia> 
phragm  being  absent.  There  was  talipes  valgus  on  both 
sides,  The  right  arm  was  well  formed  and  muscular. 
The  left  was  very  short,  with  the  elbow  webbed ;  it  bore 
only  two  digits. 

The  external  organs  of  generation  consisted  of  three 
wart-like  protuberances  ever  the  pabe^.  Of  these,  the' 
central  one  appeared  pervious,  whilst  the  lateral  ones  re- 
presented the  Bcrotum  or  labia  majora.  There  was  no 
harelip,  cleft  palate,  or  any  other  external  deformity. 

Among  the  exposed  abdominal  organs  it  was  easy  to 
recognise  the  several  parts  of  the  alimentary  canal  natur- 
ally included  ■ftithin  the  abdominal  cavity,  and  the  liver 
and  }r:/f.  suprarenal  capsnio.  Besides  these  viscera,  there 
lay   in   the   part  corresponding   to  the  right    lumbar   and 


RRTHOFIBXION,   liCTOPIA   TrSOBRrM,   ETC. 


203 


long,  iind  1  incli  adross,  with  a  finger-liko  process  on  its 
anterior  surface  flbout  J  inch  long.  This  body  wan  placed 
bcbind  the  peritoneum  covering  the  posterior  fibdominal 
wall.  On  the  other  side  of  the  abdomen  in  the  iujyuiual 
region  was  a  pale,  oval  body  ^  inch  long,  looking  cxnctly 
like  B  fundus  uteri,  with  a  flocculent  proooss  ou  its  outer 
side  resembiing  the  Fallopian  tube.  This  body  was  oon- 
neeleil  with  the  deeper  parts  on  its  inner  aide  by  a  thin 
white  cord ;  it  induced  me  to  consider  the  fcetiis  a 
female,  especially  as  I  understood  that  the  twin;*  had  lain 
in  a  common  amniotic  sac,  audi  that  the  other  was  a  female. 
It  turned  out,  however,  to  be  a  male.  Tht)  large  oval 
mass  on  the  right  side  was  the  right  kidney,  with  tho 
right  lOBticle  closoEy  applied  below,  and  the  right  supra- 
rcnftl  body  on  its  upper  surface.  The  left  kidney  was 
wanting. 

Description  nf  Separate  Parle. 

Gknito -OBI NARY  Tract. — The  one  kidnfitj,  situated  as 
above  deHuribed,  was  very  hydronephrotic,  but  had  a 
pervious  ureter  which  led  normally  into  tho  bladder.  It 
was  not  a  horseshoe-kidney,  and  there  was  no  trace  of  a 
second  ureter.  The  bladder  was  normal,  except  in  its 
relation  to  the  coccyx,  posterior  to  which  it  lay.  A  bristle, 
easily  passed  down  the  urethra  and  emerged  at  the  centrnl 
wart-like  protuberance  on  the  pubio  region  above  men- 
tioned. 'ITie  left  t^prarenal  body  was  about  one-third 
tho  sixe  of  the  right. 

The  fingor-like  process  referred  to  above,  consisted  of 
epididymis.  It  corresponded  to  the  flocculont  body  on 
the  opposite  side  of  the  abdomen,  attached  to  what  waB 
supposed  to  be  tho  uterusj  but  was  really  thy  Uft  ietttirle. 
Thus  the  right  testicle  lay  immediately  beneath  the  kidney. 
Both  teHticles  had  well-formed  vasa  dcfercntia,  which  led 
to  the  back  of  the  bladder.  The  single  ureter  ran  close 
to  the  right  vas. 

ALlUEiNTAiiY  Stbtkm. — Tbo  alimentary  canal  was  norinal 


SOi 


DieSECTIOH   0?   1  FrETDS,   THB   SUBJECT  OP 


(IS  far  as  the  rertam,  except  that  there  was  no  vfirmifoTm 
appendiiD.  The  vitello-intestinal  duct  was  verj  coDRpicuons 
And  about  three  inches  in  teugth.  Tfc  ended  in  the  remains 
of  the  yelfc-sa^.  The  large  intentine  was  greatiy  distended 
and  ended  in  a  blind  attachment  to  the  coccyx,  thns 
lying  in  front  of  the  bladder,  which  was  ahove  and  behind 
the  pubes.  The  anue  was  imperforate,  and  consisted  of 
a  dimple  an  eighth  of  an  inuh  deep  in  the  normal  position. 
From  this  dimpio  on  its  deeper  surface  was  prolonged  a 
fibrous  cord  which  ended  in  a  masa  of  fihrona  tissue  between 
the  ischia,  where  it  met  the  termination  of  the  spinal  cord. 
The  liver  was  normal  in  appenrance,  bat  slightly  altered 
in  shape.  The  spleen  was  at  the  right  side  of  the  abdo- 
men. 

OiRCt3LATOBy  Stbtem. — The  heart  was  entirely  nutBide 
the  thorax  owing  to  thodefonnity  of  the  latter,  as  will  be 
descnbed.  The  foramen  ovale  was  open,  and  the  soptum 
vontriculornm  incomplete  at  its  upper  part  As  the  entire 
ORvity  of  the  thorax  waa  tonstitnted  by  wlmt  ought  to 
h&ve  been  only  the  right  half,  the  vertebi-al  colnnin  lying 
in  the  left  division,  the  aorta  descended  on  the  right  side 
of  the  spine,  having  cnrvod  over  to  the  left  and  backwards 
in  the  normal  manner.  The  left  vagua  and  recurrent 
laryngeal  nerves  bore  their  usual  relations  to  its  arch. 
The  BHbseqnent  course  of  the  aorta  was  peculiar,  and  will 
hest  be  nuderatood  hy  referring  to  the  dia,gram  (Fig.  2). 
Juat  below  the  level  o£  the  liver  a  large  branch  was 
given  off,  from  which  sprang  the  renal  artery  (3),  the 
superior  mcBcnteric  (4),  the  right  and  loft  siipraronals 
(5  and  6),  ii-nd  the  hepatic  (7)  in  the  order  mentioned  ; 
tht'  renal  arising  very  close  to  the  aorta.  Almost  opposite 
this  largo  trunk  the  left  common  iliac  {2)  came  off,  and 
here  it  must  be  considered  the  aorta  divided.  This 
common  iliac  immediately  crossed  the  bodies  of  the  verte- 
hne  (Ijaee  of  the  sacrum),  sent  a  few  branches  to  the 
parts  in  the  left  iliac  foKHii,  and  was  continned  aa  the 
femoral.  The  rest  of  the  aorta,  or  more  properly  the  right 
common  iliac  artery  went  on.  Laming  now  to  the  right,  to 


HBTHOfLEIlONj    ECTOPIA    VIgCKKUU,    KTC. 


205 


become  the  one  ambilical  iirtery,  previously  giyingoff  tbe 
right  femora]  deep  dowu  in  the  pylvia,  and  an  artery  to 
eacb  v&a  deferens,  with  soma  amatl  vesical  and  other 
.branches.  The  umbilical  artery  ran  above  the  level  of 
the  kidney  to  the  amaion  formini^  the  right  half  of  tlie 
abdominal  wall,  on  the  edge  of  which  it  ended,  and  where 


V 


r^/ 


10 


fi 


Fte.  2. — Sclieme  of  aortic  bnuoli«i.  1.  Aorta.  %■  Left.  iLi^ic 
art*Tj'.  n.  Hcnal  artery.  4.  Sujwrloc  inciipnteric  nrler,\ . 
&  nnil  6.  (tight  nnd  loft  ftiitirfirsnril  nrleriM.  7-  Hppntiit 
urUry.  8.  Kighe  iliac  uriety.  0  •iid  10.  BigliE  and  left 
dcftrrcntinl  ttrlnriw.    11.  UnibilimI  entity, 

it  donbtlftRs  at  once  entered  the  placenta.  The  xmni 
followed  much  the  Baine  courae,  the  only  fresh  pecu- 
liarity being  that  the  utnbilical  vein,  inxtcad  of  runntnff 
along  the  under  surface  of  the  liver^  ran  to  the  right  of 
that  organ,  sent  a  few  branches  to  it,  end  joined  the  vena 
cava  inferior  just  above  it. 

Respibatokv  Systbii. — ^The  hings  contained  no  air,and  uo 
part  of  these  organs,  excepting  a  small  portiou  of  the  right, 
lay  in  the  thorax.  The  luryux  and  traclieu.  wcro  nonnal. 
The  thytnun  gland,  a  part  of  the  right  lung,  tbe  ocsophsgue, 
and  the  aorta  occupied  all  the  existing  thoracic  cavity. 

Mpscdlar  Systkk. — Tlit-  muscles  of  the  back  were  very 
ill-developed  on  Che  left  side,  tbe  spine  running  close  to 
the  left,  edge  of  the  thorax.  The  glutsei  mBximi  were  very 
small,  and,  in  the  absence  of  a  sacnim  in  iti*  usual  position, 

TOL.  xxxii.  15 


2U6 


DISSBOTiOH   OS  A   FU;i'DS,  tBS  SVSISCX  OX 


arose  mostly  from  a  tendinous  median  septum,  but  also 
from  the  first  and  second  lumbar  arches.  The  left  rectus 
abdominis  mnsole  only  was  present.  The  muBcleft  of  the 
legs  and  right  arm  were  well  developed,  tut  in  the  left 
several  were  missing,  owing  to  the  absence  of  the  ulna. 

Neevods  System. — Srain  and  head  normal.  The  spinal 
em-d  was  uot-mal  in  appearance,  but  ended  opposite  tlio 
budy  of  the  fifth  Iiimbur  yertebrte.  The  Slum  termiiiale 
ran  back,  leaving  the  body  oE  the  sacrum,  to  the  mass 
of  fi.brouH  tissue  between  the  iachin,. 

Skeleton. —  Vertebral  Column  :  There  was  a  spina  bifida 
occulta,  involving  the  two  lowest  lumbar  and  all  the  sacral 
vertebrffi  in  suoh  a  way  that  the  arches  oE  al!  those  ver- 


,4a<l 


:ii 


'^: 


v/vfi 


VlB.S. — Sliawinj^flirnn^cmtnt  orUminm  ami  rilx, ipi u*  tiiAdn, 
npproiitnatian  «f  iachlal  tnlifriMitiix,  niiil  flecion  uf  ajunr, 
Doltei!  liiic=(.-nittinunti()it  uf  Bti»(itn  and  coccyx. 


tfbriB  were  crowded  together  above,  leaving  the  pn.sterior 
aspect  of  the  bodies  exposed  below.  Above  this  mass  of 
arches,  which  consisted  o£  n  solid  plate  of  bone  and  car- 
tilage, the  first  throe  lumbar  vertobraj  had  only  half-duve- 


SBTEOrt-SJCIOK,   BCTOPIA   TTaCBRDM,    ITC. 


207 


loped  latiiiDee,  the  ends  of  which  were  able  to  comfi  in 
contact  to  complete  the  spinel  canal  owing  to  the  retro- 
flcsiiiu. 

The  right  pedicle  and  lamina  of  tho  twelfth  dorsal  verte- 
bra were  absent.  The  Hght  half  of  the  body  of  the  aauae 
Tcrtobra  was  ahsont,  vanishing  off  like  the  point  of  a 
wedge  from  tho  left  aide.  In  tho  body  of  the  ninth  dorsal, 
the  right  aide  was  cadevaloped ;  bat  the  arch  vta&  com- 
plete. 

The  left  eleventh  and  twelfth  laminie  corresponded  ^vith 
and  met  the  right  eleventh ;  the  end  of  the  tenth  right 
did  not  meet  the  tenth  left,  biit  lay  just  below  it ;  and  next 
above  the  tenth  left  came  tlie  tip  of  the  ninth  right,  and 
then  that  of  the  ninth  left.  There  was  tlrna  a  displace- 
meut  downwards  of  the  ninth  and  tenth  right  liimimtj  with 
reference  to  the  corresponding  left  larainai, giving  a  pecnliar 
plaited  appeni-auco  to  this  part  of  the  spine?.  Above  this, 
and  up  to  ihe  fourth  incln8ivt>,  the  ends  of  thelamiure  lay 
opposite  each  other.  The  thirdj  second,  and  first  dorsal 
vertebrae  hml  the  same  peculiar  arrangement  hr  the  uiuth 
and  tenth,  the  right  laminte  Iving  below  the  left. 

Tlic  cervical  vertebrie  and  skull  were  normal. 

The  ttemvm  was  .short  imd  very  broad,  but  not  fissiirnd. 

There  wore  only  eleven  complete  ribs  on  the  right  side. 
The  tenth  and  eleventh  wore  fused  into  a  broad  plate  »t 
their  outer  extpcmitiei?,  and  the  twelfth  was  represented 
by  a  spur-like  process  on  tho  lower  bonlor  of  this  plate. 
The  left  ribs  were  closely  applied  to  the  bodies  of  tho 
Tertebne,  winding  round  them  (Fig.  4), 

The  whole  ><pinal  colnnin  curved  backwards  and  to  the 
right,  to  the  extent  shown  in  the  figures,  and  ronghly  round 
R  radins  of  about  2J  inches.  The  curve  was  ncute  in  the 
lumbar  region,  where  the  hiatus  in  the  roof  of  the  canal 
at  the  level  of  the  first  three  lumbar  vertebrae  occuri'ed. 

The  pehHs  was  much  diatoitcd,  nnd  the  dir^tortion  was 
duo  more  to  the  relative  poeition  of  the  bones  to  one 
another  than  to  malformation  of  individual  bones.  The 
true  pelvis  was  prnctically  reduced  to  a  more  irregular 


208 


mssBcnos  of  i  fottcb,  the  bifajbot  or 


fissore  between  the  pabic  and  ischial  bones  on  eacli  side, 
as  the  tubera  ischii  were  almost  in  contact  (Pig.  3)  and  the 
pubic  sjmphysis  cloeed.  The  ilia  -were  so  placed  that  the 
uoraisiUy    anterior  internal    aspect    looked    slightly    ont- 


f^ 


jup 


Pro.  4.— Showing  ilinpe  of  iliorBX.  fleKion  of  tpiuv,  vvenion  of 
tllH,  Had  jMnUiim  of  coccyx. 

wardB  (Fig.  4),  and  their  surfaces  were  convex  anteriorly. 
When,  h"wever,  tlic  tubera  ischii  wore  separated  and  put 
in  their  normal  position,  nnd  the  innominate  bones  beat 
fonvanls  on  the  t^acrum,  tlio  pelvis  did  not  appear  much 
distorted.  In  the  original  position  the  acetabiila  lookotl  ■ 
almost  directly  backwards.  The  whole  pelvis  faced  con- 
siderably to  the  left,  this  being  due  pnrtly  to  the  flexion 
of  the  spine  in  that  diiertion  and  pnrtly  to  the  pelvic  dis- 
tortion. The  fi'nioral  H.rticula.tioiis  were  normal.  The  left 
OB  initominatimi  was  a  trifle  smaller  iu  every  way  than  the 
right,  espocially  in  the  length  of  the  iliac  crest.  The  right 
crest  mensnved  1^  in.,  the  left  IJ  in,  The  loft  anterior 
■Riiperior  f;pinc  was  bont  bncUwnrda  more  than  the  right, 
and  lay  more  in  a  vorlical  line  over  the  tuber  iachii  than 
on  tlie  rii^ht  sido.  Tht  left  ala  of  the  Hacrrnm  was  rudi- 
mentary, the  right  being  normal. 

JjKKi  v\iiM, — The  uliia  was  absent.  Articulated  to  the 
rndiits  was  a  cnrpus  of  three  bones,  presumably  scaphoid, 
trapezium,  and  trapezoid ;  the  two  latter  each  boro  a 
digit. 


RBTBOrLEXlON,   IlcrOPU   T18CKRDH,   KTC. 


209 


I  have  doacribed  thia  coUeetion  of  deBormiticB  rathyr 
fully,  as  it  aeyma  to  rae  tn  a  great  extent  to  carry  its  his- 
tory and  mode  of  production  written  on  its  features.  Ab 
to  its  caut;e  there  are  many  suggestive  poinlii.  In  their 
paper  publisliied  in  vol.  xxvi  of  the  Society's  '  Transactions,' 
Dra,  MattLewB  Duncan  and  Hnrry  have  fully  disctissed 
tlie  subject  of  retroflexion  of  the  foetus.  They  explain 
this  deformity  in  cases  wliere  there  is  no  cord,  as  in  the 
preaoat  iustauce  thus  : — "  The  abdomen  oE  the  foetue  is 
firmly  held  by  its  attachment  to  the  placenta  in  the  e^g- 
Hhapcd  cavity  of  the  nterus.  Tho  two  cuds  of  the  ftt'tal 
m&68j  cephalic  and  pelvic,  are  pushed  buckwards  for  want 
of  room,  and  flt-xion  is  on  the  fixed  point,  namely,  tho 
placenta  forming  the  anterior  abdominal  fu-'lJil  wall. 
When  the  placenta  is  median  as  regards  the  fcetus,  tho 
retroftexiow  is  direct — tliat  is,  without  lateroflcxion.  On 
the  other  Land,  the  further  the  attachment  of  the  placenta 
is  from  the  median  line  the  gi'eater  vrill  bo  the  lattro- 
£exiOD." 


V 


'A, 


t 


wRa> 


PiQ.  3.— Attitnilo  of  fatUB  im  utnv.     Ifotteil  line  reprcKnU 
aUrinc  wall. 

This  expUnatioQ  will,  I  think,  apply  to  tho  prosont  caso. 
In  fact  it  ia  at  once  auggested  on  looking  at  the  specimen 
in  the  position  shown  in  Fig.  'i ;  also  in  tho  skeleton.  Fig.  4. 
Uere  it  ia  seen  that  the  fistus  retain.*)  the  curve  which  the 
inner  surface  of  the  uterus  f^avo  to  it,  and  ahows  well  the 
effects  of  pressnru  on  the  side  which  was  iigainst  the  utei-iuo 


210 


DisBXcnoH  or  &  totos,  tbb  auBiBCT  or 


wall,  namely  the  left.  The  left,  no  doubt,  was  against  the 
uterine  wall,  or  rather  against  the  placenta,  because  a 
little  of  the  right  side  of  the  abdomen  was  covered  with  a 
flap  of  skin  and  amnion,  and  the  IcFt  uncovered,  Unfor* 
tuuately,  the  placenta  was  detachitd  from  thefcetus  during 
Inboar,  and  was  not  preserved.  lu  addition  to  the  absence 
of  conl,  there  was  another  factor,  the  presence  of  a  twin 
in  the  uterus,  t«nding  to  keep  the  deformed  foetus  against 
the  wall ;  though  the  effect  of  this  last  could  not  hare 
been  of  any  importance,  as  the  pressare-effectB  were  all  on 
the  nterine  side. 

These  pressnre-effecta  were  ■. — ( 1 )  Flattening  of  the  thorar 
backwards  and  to  the  right,  obliterating  the  left  half  of 
that  cavity  and  causing  the  left  ribs  to  be  closely  wound 
round  the  vertebrnl  column.  (2)  Incomplete  develop- 
ment  of  the  left  arm,  and  all  the  muscles  of  that  side  of 
the  trunk.  (3)  Flexion  of  the  spiue  at  the  lumbar  region 
to  the  right  and  backwards.  (4)  Flexion  of  the  whole 
pelvisin  the  same  direction.  (5)  Extension  of  the  thighs. 
(6)  Rotation  outwards  of  the  knees  and  eversion  of  the  feet, 
the  laet  being  the  easiest  way  in  which  the  feet  could 
follow  the  surface  of  the  uterue. 

Internally,  the  abuormalittes  were  nearly  all  on  the  left 
sideband  could  be  accouuted  fur  by  prestiure  arising  during 
the  middle  months,  though  perhaps  the  complete  absence 
of  the  left  kidney  and  ureter,  and  (?)  of  the  left  nmbilical 
artery  could  not  admit  of  the  same  explanation.  Those 
abnormalities  were: — (1)  Absence  of  the  left  umbilical 
artery,  posaibty  due  to  compression  of  the  left  iliac  against 
the  bodies  of  the  vertebra)  when  it  crossed  them.  It  wiU 
be  remembered  that  the  aorta  lay  to  the  right  of  the  spine. 
(2)  Transference  of  the  spleen  to  the  right  side.  (3)  Small 
»iKB  of  the  left  suprarenal  body.  (4)  Expression  of  the 
left  lung  and  collapse  of  the  left  side  of  the  thorax. 
[5)  Small  size  of  the  left  innominate  bone.  ((>}  Absence 
of  all  aortic  branches  except  the  iliac  on  the  left  aide, 
the  loft  supnirenal  arising  from  a  branch  on  the  right  aide. 
The  artery  to  the  left  Tas  deferens  roee  from  the  right  iliac. 


BETBOPIiBXION,    ECTOPIA    VI90BRTIM,   BTO. 


21] 


The  kidney  and  the  abnormality  of  tlie  gut  will  bo 
cousidcred  later  on. 

Tho  rectum,  BUpposiog  it  to  have  been  ncrrma.!,  would 
have  been  unable  to  jota  the  anal  involution,  for  tho  site 
of  the  anas  was  earned  far  buck  with  the  pelvis.  Tho 
testicles  were  prevented  from  deecendin^  by  the  nbsence 
of  inguinal  canals,  and  by  the  great  disturbance  in  the 
proHsure  of  tho  abdominal  walls  and  the  relations  of  the 
riscera, 

Ahlfeld,Forster,Vrolik,Bud  Ilouel  mention  and  comment 
upon  the  association  of  retroilexion  and  ectopia  viscerum, 
and  they  all  have  conjectural  hypotheaca  on  the  subject. 
The  conflicting  opinions  and  theories  of  these  four  aothori- 
tiea  require  some  consideration. 

Ahlfeld  ('  Die  Misabild.  des  Menachen,'  PL  2,  p.  201) 
believes  that  the  vitelline  duct  ma,y  persist  and  remain 
firmly  attached  to  the  intestine.  Then,  in  case  of  sudden 
incrcfLSo  of  amniotic  fluid,  the  duct  drags  on  the  coil  of 
glib  found  in  the  bs3e  of  the  cord  up  to  the  third  month, 
prevents  its  recession  into  the  abdomen,  and  may  gradu- 
ally drag  out  the  whole  abdominal  contents.  This  traction 
acts  through  the  mesentery  on  the  spine,  dragging  it  for- 
wards and  caiiaiug  retruflesion. 

Forster  ('  Mis«bild.  d.  Mensch.,'  p.  110)  says  that  it  is 
duo  to  two  causes.  (1)  The  absonco  of  abdominal  wall 
and  abdominal  contents  leaves  the  spine  unsupported  in 
frontj  nnd  it  therefore  bulges  forwarda.  (2)  The  weight 
of  tho  same  contents  tends  to  drag  the  vertebrse  forward 
olao. 

Vrolik  ('Tab.  ad  UluBtr.  embryogen.,' pi.  21  and  22) 
oonsidem  that  the  association  is  due  to  the  last-mentioned 
cause. 

liouel  ('Soc.  de  Biolog.,'  1858,  iv,  p.  55)  rcvorsca  the 
order  of  causation.  Ue  is  of  opinion  that  tho  bunding 
bnckvrards  of  tho  trunk  so  dimiuiithos  tho  thoracic  and 
abdominal  cavities  that  they  arc  unable  to  hold  their 
Dfttaral  contoDta.  He  considers  the  shortness  of  the  cord 
to  be  the  primary  fault. 


212 


DISSECTION  07  A  F(ETC8,  TEE  BCflJECT  O? 


(The  opinions  of  the  Inst  two  unthoi'Lties  are  quoted 
from  Duncan  and  Hui-ry's  paper.) 

It  is  impoiisiblB  to  accept  the  gnggestioiiB  ot  Ahlfeld, 
PoTster,  and  Vrolik.  They  produce  no  facts  to  prove  that 
such  forces  as  tbey  mention  are  in  action.  These  alleged 
forcea  are  dragging  of  the  viscera  forwards  by  biieir  weight 
or  by  the  vitelline  duct,  and  the  tendency  of  the  spine  to 
bulge  forw&rda  if  the  abdominnt  organs  be  not  applied  to 
it.  Supposing  that  part  of  tbe  intestine  were  dragged 
forward  to  any  oxtentj  it  is  the  mesentery  which  would 
give  way,  or  the  intestine  would  be  ruptured  (as,  it  is 
said,  sometimes  occurs)  hefore  the  hastnal  concavity  of 
the  embryo  coidd  be  inverted. 

The  matter  is  different  if  the  fau)t  lie  in  the  allantois, 
assuming  this  to  be  an  organ  projected  from  the  hind  gut, 
as  is  usually  taught.  Tfaia  has  a  fixed  attachment  to  the 
solid  parts  at  the  tail-end  of  the  embryo.  If  the  skeleton 
of  the  present  esnrople  be  cxamiTied,  it  will  bo  seen  that 
the  saorum  and  ooccyx  have  kept  well  to  the  front,  and 
that  the  yielding  has  taken  place  mainly  at  the  sacro-iliao 
joint. 

Against  Houol'ti  hypothesis  the  case  of  retroflexion 
caused  by  amniotic  taudB,  figured  and  described  in  the 
aforesaid  paper,  is  evidence,  there  being  no  protrusion  of 
viscera. 

lu  the  specimen  ot  retroflexion  in  a  tenth-week  embryo 
described  by  Mr.  Lockwood  ('  Trans.  Obst.  Soc.,'  vol. 
xxis),  there  is  no  protruaion.  The  deformity  in  this  laab 
caao  is  due  to  absence  of  medulla  spinalis  and  consequent 
restricted  development  of  the  dorsal  side  o£  the  embryo, 
It  aeetUB,  thereforcj  that  retroflexion  and  ectopia  may 
occur  independently,  though  they  are  as  a  rale  aesociated. 
To  some  independent  cause,  as  in  the  above  cases,  must 
bo  attributed  examples  of  retroflexion  when  the  cord  is 
sufficiently  long. 

In  the  present  specimen  there  was  probably  a  common 
cause,  and  the  case  would  be  most  simply  explained  by 
some  deficiency  in  development  of  the  hind  gut  and  its 


CETROyLKXlON,    BCTOrU   TieCERUM,    BTC. 


313 


processes.  Tliis,  it  will  be  remembered,  was  so  far  abnorni»I 
that  tlie  rectum  ended  bliadly,  beiug  atta'ched  to  tlm  tip 
of  the  coccyx. 

In  A  paper  on  the  derelopment  of  some  parta  of  the 
vascular  system  ("  Early  Development  of  Paricardinm, 
Diaphragm,  and  Great  Veins,"  '  Phil.  Trans.,*  vol.  olxxix 
[1888],  B.,  p.  3t>5)  Mr.  Lockwood  has  showu  that  the 
formation  of  the  umbilicnt  veins,  at  nil  events^  is  inde- 
pendent of  the  altantois.  He  biclidves  that  the  latter 
structure  in  rabbits,  and  pi-obably  la  man,  does  not  grow, 
as  in  the  chick,  in  the  shape  ot  a  vascular  protrusion  from 
the  hiud-gut,  but  that  the  extension  of  the  hind  gal  inti} 
the  fcetal  pUceuta  is  a  process  of  lucluaion  and  not  pro- 
LrusLOD.  According  to  him,  the  fcetal  placenta  is  formed  out 
of  a  portion  of  the  caudal  end  of  the  embryo  which  never 
becomes  detached  from  the  endometrium.  The  cord  is 
then  developed  by  lengthening  of  the  bridge  of  tiHsue, 
vesBoiB,  part  of  included  portions  of  hind  gut,  &o. 

If  this  method  of  development  of  the  placenta  and  cord 
be  accepted,  it  is  easy  to  understand  how  the  abdominal 
surface  of  the  foetus  was  kept  iu  close  contact  with  the 
utoruH.  The  stroctures  forming  the  cord  failed  to  develop 
to  their  unnal  extent,  and  thus  prevented  the  closure  of 
the  abdomen.  The  right  umbilical  artery  only  could  be 
found,  the  absence  of  the  left  being  due  either  to  original 
failure  to  develop,  or  to  absorption  from  pressure  on  tho 
loft  side.  The  right  kidney  was  hydronephrotio,  probably 
through  obtjtnictioii  to  outflow  of  the  nrine.  Tho  left 
kidney  and  ureter  were  absent,  having  perhaps  been  ab> 
sorbed  owing  to  completo  obstniction  at  the  allantoic 
(bladder}  end  of  the  ureter  at  a  very  early  period.  Mr. 
Bland  Sutton  has  described  a  fcetua  ('  Trans.  Path.  Soc./ 
1888)  in  which  there  were  neveral  malformations  of  the 
alimentary  tract,  assuciuted,  as  they  frequently  arc,  with 
spiuu  bifida.  Uu,  in  common  with  other  obHervcrH,  iti  of 
opinion  that  the  spinal  cord  is  to  be  regarded  as  a  highly 
di£foreutiated  section  of  the  priiuitivo  alimentary  tract,  and 
that  the  almost  coostaut  asttociation  of  defoctti  iu  the  two 


214 


UtSSEOTION    OF   A    FOCrLie,    TIIS   SUBJECT   OF 


B^steniB  is  thus  explained.  (See  abo  Prof.  Hamilton's 
receiit  address  to  tbe  Philoeophical  Ingtitiitioii  of  Edio- 
burgli  ou  "  The  Deyelopcaent  of  the  Nervous  System.") 

The  present  Case  was  the  subject  of  spina  biSda  occulta 
in  the  lumbar  and  sacral  regioos,  and  of  failure  of  uoion 
in  several  other  vertebral  arches,  as  doBCribed.  There 
was  also  a  cerd  Hxt&nding  from  thti  dimple  representing 
the  aauB  to  a  mass  of  tibroue  tiBsue  between  the  iscliiaj  iu 
which  uiass  the  Bpinal  cord  also  ended.  It  is  therefore 
possible  that  the  origin  of  the  spinal  intLlforniation  had 
an  intimate  cioniicction  with  the  origin  of  those  of  the 
alimentary  tract.  On  the  other  hand,  in  this  particular 
caao,  as  the  spina  bifida  occurred  at  the  point  of  flexion, 
it  might  have  been  due  to  defective  development  of  the 
arohes  from  their  being  vertically  compressed  owing  to 
the  concavity  at  this  point,  where  a  meningocele  probably 
formed.  This  seems  more  likely  from  the  appearanee  of 
the  upper  bonndsry  of  the  hiatus,  where  there  wan  a 
Bolid  tunnel  formed  of  impacted  archea,  the  mass  of  fibrous 
tisiiue  between  the  ischia  being  possibly  the  remains  of  the 
meningocele  euc. 

It  might  further  be  said  that  the  spina  hilida  was  an 
expression  of  an  abnormality  iu  the  epiual  cord  which  gave 
riuu  to  the  imperfect  left  arm  and  the  talipes.  Against 
this  theory  is  the  fact  that  the  spinal  cord  showed  no  sign 
of  cystic  dilatation  at  nuy  part,  and  was  quite  normal  at 
the  «plit,  which  waa  therefore  due  almost  certainly  to 
meningocele  and  not  mytiocole.  The  former  is  a  com- 
moner cause  of  this  deformity  than  the  latter. 

The  displacement  on  one  another  of  oppoBite  halvoH  of 
the  vertebral  arches  higher  up  was  doubtless  due  to  the 
flexion. 

The  fcetua  described  by  Mr.  Uodges  at  the  last  December 
meeting  of  the  Society  displayed  deformities  similar  to 
thoi*e  which  may  be  seen  in  the  present  specimen.  The 
dissection  of  that  fa-tua  would  liavc  proved  most  instruc- 
tive in  connection  with  the  subject  of  this  paper.  Mr. 
Hodges  kindly  tried  to  obtain  it  for  mc,  but  was,  unfor- 


SET&OFL&StOii 


215 


tunatoly,  unsuccessful.  In  addition  to  other  malforma- 
tions, the  foDtiis  was,  it  will  be  romomliored,  A.tiQncep?ialic. 

Conclimtms. — The  following'  coiiclusiuiiji  are  offered  : 
Retroflexion  and  ectopia  viscerum,  although  as  a  rule 
assaciutod,  may  occur  inJepeudeutly.  Tliey  may,  iliere- 
foro,  be  associated  and  yet  not  hare  a  common  caiiSK. 

The  only  apparent  manner  in  wticli  a  common  cauns 
could  act  is  that  described  by  Duncan  and  Hurry,  namely, 
by  shortening  or  absence  of  the  umbilical  cord,  the  abdo- 
minal snrface  of  the  foetus  being  thereby  held  fast  to  tho 
uterine  wall  nnd  placenta.  The  latter  by  its  close  appli- 
cation prevents  closure  of  the  abdomen,  keeping  apart  the 
oontripetally  growing  edges  of  the  abdominal  walls. 

This  common  cause  is  failure  in  development  of  the 
hinder  part  of  tho  gut  and  its  procesaes. 

To  apply  this  to  the  present  case,  the  coutbo  of  events 
wag  probably  as  foUowe  : 

I,  Imperfect  derelopment  of  the  hinder  pait  of  thegiit> 
aud  therefore  of  the  allantoic,  reaalting  in  (a)  absence  of 
tbo  umbilical  cord,  and  (F)  of  one  of  the  vessels  (nmbilical 
arteries)  normally  projected  on  tho  allantois;  [b]  interfer- 
ence with  the  outflow  of  urino,  possibly  at  the  allantoic 
end  of  the  urotoi's,  producing  right  hydronephrosis  and 
ftbsenceof  tho  left  kidney  aud  ureter.  Resnltiug  from  (a), 
olo»e  application  of  fcctiis  to  placenta  and  uterine  wall  : 
causing  (re)  Hexioa  with  its  effocts  on  tho  epine  (menin- 
gocele and  spina  hitidn  occulta]  ut  the  point  of  flexion  ; 
Jh)  pressure  effects  on  the  rest  of  the  body ;  (c)  failure  of 
abdominal  wall  to  close. 

Mr.  Albam  Doran  ainoerifly  hoped  that  Fellows  of  the^ciety 
would  imitate-  0r.  Dalfiu  and  hriog  forward  carvfulty  prepared 
papers  on  spfciitl  cuxes  of  mouHtrositj.  or,  Wtter  still,  on  noma 
eDtire  cIm-i  of  mousttT.  Tho  Soeiotjf  ufTL'red  particular  adran- 
tageti  fur  the  dvmoutitraliou  and  pubhcatioa  of  mattriiil  uf  thi« 
kind  which  othorwisi'  would  be  lost,  for  oheervers  cuuld  not  he 
«ipected  to  pubhiih  toratole^cnl  eisays  at  thmir  uwu  vxiwuse. 
TcratologY.a  very  iwportantbnt  iu  certain  rcKpi?ct«  unproblable 
science,  had  been  Inft  too  much  to  the  French  and  uermans. 
The  Society  wait  in  a  position  to  wipe  awn,y  that  reproach. 


216 


A  CASE  OP  SPURIOUS  PREGNANCY  SIMU- 
LATING  ECTOPIC  GESTATION. 


By  E.  SiNciJLiK  Stevenson,  F.R.C.S.E.,  &c., 

KOKUKBOSCH,  CJFB  TOWS. 

( Ki^cuvcd  November  2l8(,  l&gO.) 

Mks.  S — ,  ujt^ed  24^  3-pfvra,  tLioe  abortioiis,  lufsfc  child 
boiii  in  April,  1888.  A  heinltUy,  geuerallj  briffht  persoD, 
and  not  in  any  way  norrous  nor  hyst'erioal. 

She  ment^trnntud  la>it  in  September,  ]888,  and  from  that 
timo  she  conchided  that  ulie  had  btjconie  pregnant.  She 
foH  then  as  shu  had  iilwayH  felt  when  in  that  condition  on 
previous  occasions. 

In  January^  18S0,  she  says  that  she  had  sevore  pains 
&iid  a  bloudy  discharge,  and  thought  that  she  wan  going 
to  luiscnrry,  but  she  got  over  this  attack,  and  quickened 
ub  the  expected  time. 

In  April  the  movements  oi  the  footus  were  distinct. 
This  statement  was  corroborated  by  her  hnsband,  atster, 
and  fi-ieijds  who  saw  her.  The  abdomen  was  enlarged 
and  the  breasta  much  developed. 

In  April  labour  began,  and  the  patient  sent  for  a  mid- 
wife. The  pains  continuiug  for  three  days,  a  medical  man 
saw  her.  Towards  the  end  of  tlie  third  day  slio  piisaod 
from  the  vagina  what  shti  called  a  "  piece  of  skin."  The 
medical  miin  present  saw  it,  and  instructed  the  nurse  to 
send  it  to  his  house,  but  hia  order  ivas  neglected.  His 
itnpre»sinn  at  the  time  was  that  the  case  was  extra-uberine 
pregnancy. 

The  bearing-down  pains  passed  away,  and  with  them 
the  fa-tol  movcoieuts  gradually  diminished.  The  next  day 
she  had  «  profuse  discharge,  and  Iho  abduminni  swellii^ 


ePDBIOCS   PBBONAWCY  81MPLATIK0   aCTO?IC   Q88TATI0N.  217 


rapidlj  disappeared.  The  breasts  were  secreting  milk. 
From  tliat  (la.te  stie  felb  ill,  linviug  constant  pains,  nml 
euflered  from  u  imico-piiriileut  dischurge. 

At  tbc  end  o£  Jul;  I  saw  lier.  She  was  then  complain- 
ing of  weakness  and  paiu,  aucl  had  shirering  fits  and  night- 
Rveats,  Hep  tsmperatuve  whon  taken  was  iiornaal.  She 
looked  woi'u,  bnt  not  ver^f  ill,  and  was  unable  to  walk  or 
stand  withuut  inuch  pain. 

External  E.raminatinn. — In  the  right  side  there  was  a 
swelling  the  size  of  a  large  fist,  moveable,  and  changing  its 
place  according  to  the  position  the  patient  occnpied.  The 
abdomen  was  generally  tender. 

Varfinal  E^plitratuni. — Oa  large  and  patulous,  admitting 
the  index  finger  as  far  as  the  internal  os,  pointing  untcriorly. 
In  the  right  fornix  a  soft  mass  could  be  plainly  felt.  The 
nterus  was  retroverted  and  free  from  adhesions.  The 
uterus  WR8  rapidly  dilated  and  the  cavity  carefully  exa- 
mined. 

The  diagnosis  of  an  interstitial  gestation  with  rupture 
at  the  fourth  nionth  into  the  broad  ligament  was  made. 
On  account  of  hectic  symptoms  an  operation  was  advised. 
The  patient  was  admitted  into  my  privnte  hospital.  On 
August  l+th  she  was  operated  upon,  and  au  ovarian  cyst 
of  the  left  side  was  found  and  removed.  Tlio  Yiscera  were 
normal.      The  jMitient  very  soon  recovered. 

Remarks. —  1  think  that  1  may  bo  excused  this  dia- 
gnosis, r  had  boforo  me  a  chain  of  evidence,  the  liulcti  oE 
which  taken  singly  or  collectively  led  me  to  give  this 
erroneous  opinion. 

All  the  symptoms  of  pregnancy,  based  on  an  experience 
of  six  gestations,  of  which  three  came  to  full  term,  were 
here  present.  Very  clear  signs  of  ectopic  gestation  wen- 
lit  hand,  and  finally  these  two  clneses  of  symptoms  wen- 
complicated  by  a  spurious  laboar.  The  only  explanation 
that  1  can  give  of  the  above  case  is  that  some  cause  led 
the  patient  to  think  that  she  was  pregnant  at  the  time 
whon  the  tnmour  was  first  noticed  ;  that  the  tumour  grew 
at  a  pace  equal  to  that  of  s  fcetus  in  normal  gestation. 


218  BFDEIODa   7BI1GNJIHCY   SIUULATIHQ    ECTOPIC    GKBTATION. 

and  imagination  would  do  tbe  rest.      At  full  term  spurious 
contraction  took  place  and  the  thin-walled  cyst  burst. 

At  th«  time  of  the  operation  I  carefully,  bat  in  rain, 
looked  for  symptoms  of  previous  rnplnre.  One  question  I 
should  like  to  be  answered  by  the  Fellows  of  this  Society. 
May  o  cyst  which  has  burst  fill  again  and  show  no  sign^ 
o£  former  ruptiire>  such  as  adhcsioua  ttud  Other  inflam- 
matory prodacts  ? 


Dr.  SfiTTHEwa  Dcscan,  in  rpsponae  to  tho  qupstion  in  the 
paper,  said  thnt  kc  had  long  ago  publiehcd  a  case  iu  which  au 
o?ar>a.n  cjst  of  larg*  size  was  spoLtaiieously  t-vacuated  thi'ougb 
the  uterus.  Subaequently,  after  refiUing,  ovariotomy  w<L8  per- 
formed, and  then  no  trace  o£  counectiou  between  the  cyatonia 
and  the  tuhea  or  uterua  could  Ijl.'  found.  But  he  had  seen  flreii 
more  reniarbabie  inetancea  of  repair  of  analogous  kind.  A 
wonmu  wailing  for  ovariotomy  had  a  Urge  perimetric  mass  high 
behind  the  cervis  uteri,  ll  burst  aud  discliarged  pus  and  fieces 
iu  laryo  quantity.  Tho  fingvreould  easilv  pass  ihrongh  tbe  roof 
of  the  vagina  into  the  fracal  abscess.  It  soon  heiti^d,  and  iu  lees 
than  three  weeks  after  the  healiug  ovariotomy  was  performed 
successfullji.  At  the  operation  search  was  made,  but  no  trace  oC 
connection  h4>(ween  hoivel  and  vagina  could  Ive  found;  there 
were  no  adhesioiia  in  the  region  of  the  vaginal  roof. 

Dr.  HoEEocKS  mentioned  the  case  of  one  of  his  surgical  col- 
leagues wbieh  he  had  examined.  Just  before  the  operation  of 
ovariotomy  was  undertaken  tbe  patient  was  seized  with  sudden 

Eiiiu  aud  coDapsc.  She  rallied,  and  in  a  tew  days  the  tumour 
ad  almost  vniiished.  Dr.  Horroeka  again  examined,  and  felt 
the  collapsed  cy*t,  which  had  evidently  ruptured,  ponrins^  its 
contents  into  tbe  peritoneal  cavity,  frum  which  the  fluid  was 
absorbed.  In  a  few  weeks  the  cyst  refilled,  abdominal  section  was 
performed,  and  the  tumour  was  removed.  At  the  time  of  the 
opentioa  there  was  no  evideuceof  aoy  recent  peritonitis,  neither 
could  there  he  fouud  any  scar  upon  the  cyst-wall. 


FEVEE  IN   CHILDBED. 

Part  I. — Gteneril  Htoienk  asd  Antisepsis. 

Hy  Robert  Boiall,  M.B.,  B.C.CantJi.b.,  M.R.C.P.Lond., 

UimXVT  OI13TIITR1C  PHTSICIlli  TO,   AKD   LKDTcmKR  OK  PBACttClL 
UIDWIFEBT   AT,  TBB  UlDDIiKSBX   HOBFITAI.. 

(Ufrwirea  December  10th,  ISSa) 

Abstract. 

r.  Thfi  genoral  fever-rate  and  neptlf  rate  of  the  Qev-prnl 
Lyi'ig-iii  Jlospital  dnniig  (/te  last  seven  ymr» ;  marked 
deelvne. 

In  tliofiret  part  of  tliie  pappr  Iht  EaetnrB  which  litar  uiiiversiiUjr 
oil  the  »iil>jeot  are  alont>  cuiiHuloroi] ;  iinrticuluvs  porlaiiiiiig  to 
individttal  casea,  such  na  the  general  couditioii  of  the  patient  and 
tfai!  cburaclcr  oC  the  labour,  ore  itot  incladed.  In  such  an 
extondoil  series  as  that  now  presented,  tliese  items  arv  dis- 
Irihiitetl  with  siich  approach  to  uui formity  «»  to  ryiidor  the 
otniaaiou  a  matter  of  little  iniportauce. 

A  seriL-s  ttC  charts  and  tahlt-s  arc  rippfndod  whicli  deal  vrilh 
the  2762  puerperce  who  have  been  delivered  iu  the  OeaeraJ 
LyinR-in  Hospitiil  during  n  period  of  seven  years,  from  July, 
1882.  to  June,  1889,  incluBiTe. 

The  figures  upon  wLich  Charts  I,  II,  aod  UI  are  construiited 
are  given  ia  Table  I.  The  readinga  ai-e  all  taken  from  the  base 
liuo. 

By  thia  mean$  it  will  be  jtrcved — 

(1)  Tltal  Ihe  j)ri>jiortion  of  case*  fij^fct«d  with  /ever  ducUned 
ra^dlt/  and  t)wn  beraiae  tteady,  but  haa  idnce  dimini«hfd  tlightly. 

(2)  That  ihi»  decline  hat  m  the  main  vaulted  from  decrease  in 
andtanporary  abolition  of  taaea affected  witk  ii2>iicKmia  and  pelvic 
it\fiammittioa. 


220 


FBVER   IN    CUILUIIED. 


(3)  Thai  in  the  febrilf^  catea  both  the  duration  anit  /Ae  height  of 
the  f  aver  hnw.  ttimiuUhed. 

(4)  That  thete  chan<ft.t  are  ideniioal  in  point  of  time  with  etrtain 
ekangea  effected  in  [he  hospital  service. 

Cliart  I  yive«  llit-  toul  iiimiljev  of  ]mtieut«  admitted,  the 
number  of  raees  in  which  the  tciuperature  rose  ahuve  100"  P., 
the  uumber  of  patients  who  were  affected  with  aepticiemia  and 
polvic  inflamiiia,tion,  and  th&  total  average  daily  amount  of 
furei'  from  iil)  cuuaos  (L'stiiniLtCid  in  iacroiuents  above  100°  F.) 
fortach  month. 

This  thaws :  an  increase  tn  ihe  number  of  admitiiont,  a  decreaaa 
in  the  numhfr  of  ffWi}^  easet  and  jiarJieulafly  of  teptie  catft, 
and  a  diminution  in  the  amount  cf  Jeter  noi  only  relative  but 
tthiolute. 

But  OB  the  number  of  patients  iidmitkHl  mouth  b>-  mouth 

Tftiive  so  conaider&blv  as  to  render  eouipariaon  o£  one  month 

•  with  another  tt  mutter  of  difllmiUj,  separate  chiirts  based  on 

pereentagea  ant  also  ap]>ended, 

Chan  n  18  divided  into  four  pivrta ; 

The  Jirel  diviaion  gives  the  percentage  of  palieuts  in  whom 
the  temperature  rose  abi>ve  100°  F.  aud  the  percentage  of 
patients  who  were  affpcted  with  septieajiiiia  and  jxtlvic  itiflrini- 
nmtioD. 

Thit  thoics  :  that  of  the  lehole  number  of  patients  dcUftred  in  the 
hotpHitl  h'fore  and  after  May,  188i,  n  Jrop  occurred  from  S.!  per 
cent,  to  \M-{\  per  cent,  in  the  cust-t  foJioivrd  hy  fever,  and  /root 
40  per  cent,  to  2"5  per  cent,  in  the  ensea  follotaed  hij  teptie  fever ; 
and,  further,  tnJiaates  an  improvement  in  both  reitpeela  in  tht 
montht  which  immediately  precede  that  dale. 

Tit!  fecund  division  gives  llie  average  daily  purcentage  of 
patients  in  hospital  with  pyrexia  imd  with  aepticieuiia  and 
pelvic  inflamumtifln. 

It  will  be  observed  that  this  diviHion  o£  the  Rhart  takes  into 
account  both  the  proportion  of  febrile  to  iion-febrile  cases  and 
the  duration  o£  the  fover,  and  also  the  proportion  of  »eptic  tfl 
ll'>n-*Ciptic  CIW09  and  the  diirntioii  of  thp  fever  with  wbicb  thcv 
were  auooiated. 

Thiaihotct;  in  comparing  all  the  cain  lefore  and  after  Mau, 
1SS4,  a  drop  from  39  jfcc  cent,  to  8  per  cent,  in  the  dail\/  ^ropor* 


FKTKR    m   CHlliOBID. 


lion  qf  ciMCK  (It  hospital  with  fever,  and  from  27  per  ecitt.  to 
VG  per  cent,  with  itfptif  fevet- ;  and,  further,  indicatt>s  an  itn- 
proemnent  in  both  re»peott  in  fh&  months  which  ivimeitialely 
precede  that  date. 

Tbe  iMrd  divisioii  gives  the  average  duration  of  the  Sever  in 
days. 

Thii  akoips :  IB  a  comparison  of  at!  the  fehrilf  oa»f»  before  and 
aprr  Mny.  1884,  that  the  duration  of  tkn  fecer  was  rediicedfrom 
7-7  to  8  dayg,  together  with  tome  improeevwnt  in  (kit  rerpeet  also 
in  the  months  which  immediately  precede  that  date. 

The/owrtA  rftvi>w«  gives  the  avcmge  height  of  tho  fover  in 
degrwB  above  100°  F. 

Tkit  thoicx:  an  avitra^e  reduction  in  the  hciijht  of  the  tempe- 
rature dating  from  Maif,  ISH4,  of  very  nearly  1"  F.,  bat  no 
appreciable  improvement  in  iftia  retpeot  in  the  monlhe  which 
immediately  precede  that  date. 

Considered  as  a,  whole.  Chart  II  proves — 

That  not  oiiljj  has  the  proportion  of  febrile  to  iion-fchrile  cases 
dimiaithed,  but  aUo  the  proportiun  of  sepdc  to  iton-trptic  casee 
has  at  the  tame  time  vtitl  more  markciUy  dimtuished,  that  far 
months  together  such  iwint^Ji  have  entirely  dixappeared,  and  that 
limultaneojuly  the  duration  of  the  fever  hat  been  shortened  and 
itt  height  diminished. 

Chiift  III  eipresACH  these  reHults  in  a  condensed  form. 

It  gives  in  ciitliii-?  ouly  (white  on  black  ground  a»d  vice 
vend)  the  average  atnount  of  p^Toiia  from  nil  caiiS4.ii  pt>r 
pnti«nt  (in  dava  X  dogrcos  iibove  100°  F.).  It  will  liu  ob- 
Herved  thut.  being  the  product  of  the  tirst,  third,  and  fourth 
dirisiunH  of  the  pi'ccoding  chart  reduced  to  unity,  it  UikL-H 
into  account  not  only  the  proportion  of  febrile  to  non-fcbril© 
casuii  and  the  duration  of  the  fo*«r.  but  also  the  height  of 
the  temperature;  and  therefore,  a*  an  index  of  the  condition 
of  the  hospitAl  for  cacii  month,  is  not  to  be  8iir|>a6sed.  But  ws 
it  often  bap})en<'d  th£it  paticDta  admitted  towards  thn  end  ui 
oae  month  had  little  or  no  fever  until  the  following  mooth,  and. 
that  when  the  attack  vax  proluiiged  the  fev«r  was  continued 
into  the  month  following  adntianion  and  even  later,  this  line 
only  rcprpsents  approximately  the  f«ver-rato  for  each  paticob 
admitted  during  the  mouth  to  which  it  refers.  It  hu  there- 
VOL.  xxiii.  16 


S22 


FiyKE    Df   CUdDBBD. 


fore  been  j>l(iced  iinilor  tbc    betwliiig  of    "  Approxaiude  fevsr* 
rate," 

The  True  fever-raie.  i.  e.  Ilie  average  ami>imt.  of  iiyrexia  from 
all  causes  (in  davs  X  degieeft  above  100°  P.).  for  eacli  piitifnt 
admitted  duriu^  each  mouth  is  ^ireu. 

TAis  thoiee :  that  eaeh  patient  admitted  avernged  ns  much  as 
17  degrees  iff  fever  during  tkti  jmerptrium  before  May,  ISSJi,  but 
onitf  1  ileifrcK  after  that  date ;  and,  further,  that  the  amount  tost 
eoMiderablt/  redttccd  in  tha  months  whinh  immediately  prtmde  thai 
dale. 

It  may  bo  noted  that  the  Tr«s  and  Approxiviale  ftwr-rcUtt 
T«iy  nearly  coincide  when  the  cases  of  severe  and  prolonged 
illness  are  few. 

TLe  sepivs  rate,  i.e.  the  average  amount  of  pyrexia  due  to 
Beptictomift  and  pelvic  inflanimiition.  (in  days  X  degrees  above 
100"  F.),  for  eaeli  piitient  admittitd  during  each  mouth  is  aUo 
given. 

Thit  ghomt :  (hat  each  pemoti  admif/rd  averagrd  n«  much  as 
13  d^ifrces  offtferfrom  septicixntia  and  pelvic  in-jlammaiioii  alone 
dufiny  Ihit  puerperiun  before  May,  1884,  hut  /««  than  half  a 
deyree  after  that  dale,  the  amount  beiny  often  reduced  to  zero  of 
to  a  fraction  of  n  dryroe  for  montht  foyether  ;  and,  further,  that 
the  amount  wh^  appreciably  red-need  in  the  monthi  which  immS' 
diately  precede  that  date. 

This  ehart  further  demonstrateB — 

(1)  That  the  decline  in  the  general  feuwr-rate  has  in  the  main ' 
retaltedjrom  decline  in  the  septic  rate. 

(2)  That  though  occasional  alight  rises  have  occurred  during 
tie  last  fitie  year f,  the  general  tendency  has  hern  towards  improve* 
meni  not  only  in  the  general  fever-rate,  but  aho  in  Ike  septic  rate, 
and  that  when  the  general  feccr-rate  has  riten  it  has  in  the  main 
resulted  from  increage  in  the  septic  clement. 


1  pROrosR  On  the  present  occnsion  to  cnet  my  glance 
bnckwardet  from  the  erainence  of  the  General  Lyiug-ia 
Hospitnl,  orer  the  table-land  of  the  puerperal  state,  and 
would  invite  you  to  anrvey  with  me  the  subjeot  of  fever  in 
childbt^d  by  means  of  a  eeries  of  thermometric  observations 
which  have  been  carried  on  continuously  during  the  last 


FBVSB    IN    CHILDrZD. 


223 


acTen  years,  and  which,  for  purposes  of  couiparison,  are  now 
presented  iu  n  collective  form  for  encU  mouth  (pp.  235a, 
B,  c,  D). 

Tbts  subject  ie  ono  which  has  ongagod  inucb  attention, 
and  deservedly  80.  Yet  several  points  cumiectt^d  with  it 
still  remain  open  to  debate.  It  is  a.  suhject  ou  which 
suificient  has  beeu  writtcu  to  t'orrn  a  library  in  itself,  but 
I  ehall  not  attempt  to  catalog'ae  ihs  works  which  bear 
upon  it. 

Id  1884  Dr.  E.  S.  Tait  reviewed  the  subject  from  the 
eame  position  ns  that  upon  which  I  now  stand,  having  in 
the  latter  half  of  1882  recorded  a  series  of  borings  through 
the  diiferent  Btrata  of  the  puerperium.  In  a  valuable 
paper  read  befora  the  Society,  and  entitled  "Some  Observe- 
tioDS  on  Puerperal  Temperatures,"  he  drew  attention  to 
Tftrious  fftctors  which  are  operative  iu  the  producliou  of 
fever  in  childbed,  and  more  especially  to  the  iuOueuco  of 
traunitttiain/of  forceps  deliveiy,  of  lutra-utcrinu  uianipula* 
tions,  and  of  cmotioual  display,  Siucc*  that  time,  however, 
the  nature  of  the  ground,  aii  it  is  my  preseot  iuteution  to 
bkow,  haa  altered  considerably — solnuch  so,  indeed,  that 
1  trust  it  will  soon  be  possible  to  clear  up  some  at  least  of 
tbo  ambiguouB  points  connected  with  that  part  of  the 
queetiou. 

In  the  Brst  part  of  the  present  paper  it  is  my  intention  to 
deal  with  conditicua  which  boar  universally  ou  the  suhject, 
rather  than  with  ihu  peculiarities  of  individual  cases — to 
take  a  broad  survey  rather  than  make  s  minute  innpoclion. 
For  though  it  is  qnite  true  that  thecaHca  might  bo  divided 
up  into  particular  classea,  after  the  method  adopted  by  Dr. 
Tait,  each  of  which  nuay  be  shown  to  posseee  its  own  parti- 
calar  bearing  on  the  incidence  of  fever  in  childbed,  in  such 
an  extended  series  a^  thut  now  presented  theso  classes 
become  broken  up  and  distributed  with  such  approach  to 
uniformity  as  to  render  the  omission  a  matter  of  little 
importance.  In  a  subsequeut  part  of  Iho  paper  I  hopet« 
show  the  bearing  of  auch  particular  clasaoa  on  the  same 
subject. 


224 


niTKB    IB    CHILDBBD. 


I  propose,  in  the  first  place,  to  present  a  critical  csaraU 
nation  into  the  state  of  the  hospital  vith  the  aid  of  the 
appended  tables  and  charts ;  in  the  second,  to  recite  the 
menns  by  which  the  present  sstisfartory  state  of  the  insti- 
tation  has  been  attained  and  is  Htilt  maintained  ;  thirdly, 
to  relate  sach  accidental  espenences,  id  addition  to  the 
alterations  purposely  introdnced  into  the  service,  as  m»y 
have  affected  the  condition  of  the  hospital ;  and  finally, 
to  snggest  the  lesBona  to  be  derived  from  these  varioog 
oonsiderationB. 

It  may,  however,  be  advantageoQS  if  in  this  place,  and 
before  proceeding  to  discustt  the  different  sections  of  the 
paper  in  detail,  I  briefly  review  the  histoir  of  the  hospital 
during  the  last  few  years. 

In  the  years  which  preceded  the  routine  employment  of 
anti&epttcs  the  amount  of  illness,  and  especially  of  septic 
illness,  mnst  have  been  very  grave,  for  the  death-rate  (the 
only  available  gnide  to  the  condition  of  the  hospital  at  that 
time)  was  invariably  high,  bet  presented  oreat  variations 
and  often  indicated  an  appalling  mortality. 

Then  the  antiseptic  regime  dawned,  carbolic  acid  and 
Condy's  fluid  wore  regularly  employed.  Under  this 
regime  the  death-rate  declined  considerably,  and  on  the 
whole  remained  steadier.  Cases  of  illue&s  and  especially 
of  septic  illness  were,  however,  always  present  to  a  {greater 
IX  lees  degree,  hut  varied  within  wide  limits,  both  as 
regards  freqnoncy  and  severity. 

During  the  last  few  months  of  this  carbolic  and  Condy 
era  a  steady  and  appreciable  improvement  took  place,  and 
in  a  marked  degree  with  regard  to  the  cnsi's  of  b  septic 
oatnre.  This  wdr  dne  in  part  to  the  improved  method 
of  dealing  with  the  antiseptic  agents  and  to  the  meaas 
taken  to  prevent  their  mutual  destruction,  and  in  part  to 
A  more  systematic  attention  to  points  of  general  hygiene, 
particularly  as  regards  the  midwives  and  nnrses. 

When  subsequently  carbolic  and  Condy  were  replaced 
by  sublimate  a  farther  improvement  was  efEectcd,  and 
acpticiemia  disappeared  entirely,  at  any  late  for  a  tima 


yETCR    rs    CFtLDBED. 


225 


[tlie  ioetanoes  of  its  recurrence  being  few  and,  as  a  rtitc, 
far  betweou  and  of  slight  iiiteiisity).  The  death-rate  fell 
in  a  remarkable  degree,  and  from  tbat  date  until  the 
present  time  the  instaaces  of  illness  have,  generally  speak- 
ing, been  slight  and  unimporta-iit,  and  in  great  piirt  of 
an  accidental  character,  whereas  septicemia  haa  figured 
rarely. 

Nevertheless,  during  tlie  sublimate  era  tbreo  oases  h&Ta 
died  from  the  effects  of  septic  infection  ;  one  in  the  short 
period  during  which  donche-solutions  of  weak  Gublimate 
were  employed,  and  tho  remaining  two  jn  another  short 
interval,  during  which  the  snblimate  doucte  waa  replaced 
by  salufer.  During  this  period  also  the  other  instances  of 
illness  suffered  appreciable  increase. 

Several  examples  of  the  introduction  of  Kjmotic  poison 
hare  occurred,  both  during  the  time  that  fepticietnia  was 
still  rampant  and  nlso  since  it  has  been  practically  stamped 
out.  A  siugio  occurrence  of  erysipelas  during  the  first 
period  was  attended  with  a  striking  incrcaao  of  illnees  in 
other  patients,  which,  if  notabsolutel}-  identieal  with,  wag 
indietingnishnble  from  septiciemia  in  its  clinical  aspect. 
Scarlet  fever  Mveral  times  occurred  both  before  and  after 
the  elimination  of  septicaemia,  and  wne  attended  during  the 
first  period  with  a  alight  but  siiggeative  increase  in  illness 
of  a  similar  septic  nature,  but  duritig  the  second  was,  as 
alreadystatcd,  productive  of  no  appreciable  ill-effcct  beyond 
giving  rise  to  cases  of  a  more  or  less  typical  scarlatinal 
type.  And  finally,  noithor  typhoid  fover  nor  measles,  a 
Mnglc  instance  of  each  of  which  occurred  Vluring  the  first 
period,  seem  tn  have  produced  any  sucU  effect. 

Individual  instances  of  the  injurious  effect  of  foul  air 
were  now  and  ag'ain  observed,  but  since  the  winter  1882-3 
no  general  increase  in  the  amount  or  severity  of  illuesii 
Las  occurred  during  the  winter  months  as  compared  with 
the  pnrauior. 

These  points  will  be  considered  in  detail  in  the  various 
eeotioDfl  of  the  paper.  Part  1  will  be  devoted  to  the  effect 
of  general  hygiene  and  antiseptic  precautions  ;   Part  II 


226 


revRit  m  cmtDSKD. 


to  the  influence  of  zymotic  poisons  and  of  atmospherie 
changes. 

The  aceonipnnying  charts  estend  over  a  period  oF  eevon 
years,  from  July,  1882,  to  June,  1889,  inolnaive.  They 
deal  witb  no  less  than  2762  puerperae  who  were  dolivered 
in  the  General  Lying-in  Hospital,  under  the  care  of  Dr. 
John  Willioais,  Dr.  Champtieys,  Dr.  Herman,  Dr.  Culling- 
worth,  and  myself, 

Certain  eectiona  of  this  period  I  would  mention  in  par- 
ticular. The  first  of  these  compriseB  the  six  iiiontha  end- 
ing December,  1S82,  during  which  Dr.  Tait  carried  out  his 
obaervations.  The  second  extends  from  Septemher,  1883, 
to  December,  1884,  inclusive,  when,  as  houee  pliysician, 
nndor  the  direction  of  Dr.  Johu  Williams  and  Dr.  Champ- 
neySj  I  was  euahled  to  make  special  tibser  vat  ions  on  the 
course  of  the  pnerperium.  The  condition  of  the  hospital 
at  this  time  was  treated  of  in  some  measure  in  ray  com- 
munication  on  "  ScBrlntina  during  Pregnancy  and  in  the 
Puerperal  State,"  in  which  the  position  of  scarlatina  as  a 
cause  of  fever  in  childbed  was  diacussed.  The  third  and 
fourth  eectious  cover  the  last  six  months  of  1886  and  1887 
respectively.  These  last  I  propose  to  utilize  on  a  sub- 
sequent occasion  in  considering  move  pftrtioularly  the  lesa 
Bevei'o  forms  of  fever  in  childbed. 

Through  the  coiirteity  of  my  late  colleagues  an<3  of  my 
successor  I  have  been  enabled  to  fill  in  the  spaces  be- 
tween these  sections,  and  to  present  uninterrupted  charts 
for  the  whole  seven  years. 

The  result  is  instructive  as  showing  the  great  improve- 
ment which  }iaa  taken  place  in  the  condition  of  the  hospital 
within  this  period.  For  daring  the  first  eighteen  months 
the  condition  of  the  hospital  generally  may  be  described 
as  one  of  high  and  persistent  fever,  varying  much  in 
amount,  it  ia  true,  but  still  persistent.  Then  came  a  period 
of  gradual  but  steady  decline,  extending  over  some  six 
months.  Into  the  cause  of  this  I  shall  euter  presently. 
May,  1884,  marks  an  important  epoch  in  the  hospital's 
history.     At  that  iirac  fas  I  took  nccasion  to  point  ontii 


I'KVCR     IN    CDn,DRED. 


227 


speaking  on  Dr.  Dakin's  paper  oa  mercurial  ism  read  before 
this  Society  in  1886)  a  decided  imp  pavement  occurred. 
Since  tbat  time,  with  the  exception  of  oocasional  nligbt 
relapses,  a  steady  convalescent  slate  has  been  maintnined. 
UTit'se  relapses  "will  also  call  for  special  comment. 

The  figures  upon  which  Charts  I,  II,  and  III  are  con- 
etructed  are  presented  in  a  tabular  form  for  pnrpoaea  of 
reference  (see  Table  I,  p.  235l>].  Tlie  rcadiogs  arc  all 
calculated  from  the  base  tine. 

By  this  meatin  it  will  be  proved — 

(1 )  Tlutt  the  proportion  of  caBcs  affected  with  fever  do- 
cltued  mpidly,  and  then  beeame  steady,  but  has  since 
diminished  slightly. 

(2)  That  this  decline  has  in  the  main  resnlted  from  de- 
creane  in  and  temporary  abolition  of,  cases  affected  with 
septicaemia  and  pelvic  inflamniatiion. 

(3)  That  in  the  febrile  cases  hath  the  duration  and  the 
height  of  the  fever  have  diminished. 

(4)  That  these  changes  are  identical  ia  point  of  time 
with  ccrtftin  changes  effected  in  the  hospital  serTice. 

Chart  I  (p.  23yA)  deals  ia  the  first  place  with  the  total 
number  of  patieiits  admitted  (indicflted  by  a  fine  cou- 
tinuouB  line), and  with  the  number  of  patients  who  suffeied 
from  pyrexia  (indicated  by  a  dotted  line). 

The  close  approximation  of  the  dotted  to  the  thin  cnn> 
tiniionii  line  during  the  first  eighteen  mnnlhs  shows  the 
small  number  of  patients  who  escaped  pyrexia.  The  sub- 
seqncnt  separation  of  one  line  from  the  other  indicates  the 
great  improvement  which  afterwards  occurred.  Further, 
the  persistent  rise  in  the  fine  continuous  lino  denotes  tho 
increasing  number  of  patients  admitted  lo  hospital  since 
the  improvemeot  took  place. 

In  the  next  place  lie  number  of  patients  who  were 
affected  with  Kepticaimia  and  pelvic  inflammation  is  given 
(indicated  by  a  thick  continuous  line).  This  liae  closely 
coincides  in  its  variations  with  the  dotted  line,  declines 
with  it,  and  after  the  first  eighteen  months  at  times  entirely 
disappears. 


228 


rKVEK    IN    CmLDBED. 


This  shows  the  decrease  in  the  niimbpr  and  ultiiiiate  dis- 
appearance, of  septic  cases,  aouietimea  for  months  together. 
Lastly,  the  total  average  daily  pyrexia!  rise — th&t  h  to 
say,  the  nuQiber  of  degrees  of  fever  (estimated  iii  increments 
above  100'  F.))  for  diatribution  among  all  the  patieiite  iu 
hospital — iaulso  giveu  (indicated  by  a  broken  Hue).  This 
line  U  found  to  follow  the  declension  of  the  dotted  curve, 
and,  while  aoarly  approaching  Iho  fine  eontinaoOB  line  in 
the  early  monthe,  to  separate  from  it  very  widely  after- 
wards. 

This  8110178  a  diminution  id  the  amount  of  fever,  not 
only  relative,  but  absolute. 

Turning  now  to  the  figures  given  in  the  table  (p.  235d), 
and  taking  by  way  of  example  December,  1882,  it  is  found 
that  twenty-Bi-t  patients  were  admitted,  of  whom  twenty -fivo 
had  fe^cr, — all  but  one — and  tliat  of  this  number  eighteen 
had  fever  from  septicEemta  and  pelvic  iudummation  aloDO ; 
nud  that  on  au  avcrago  tliere  was  distributed  among  the 
patients  a  massed  daily  nraoiint  uf  fever  of  close  upon  19 
degrees.  Now,  by  way  of  comparison,  take  December, 
lfi84.  During  tliis  month  thirty-five  patients  were  ad- 
mitted, of  whom  only  four  had  a  rise  of  temperature  above 
100°  F.,  one  being  attributable  to  septicfemia  or  pelvic 
inflammation,  and  the  massed  daily  amount  of  fever  dis^ 
tributed  among  them  was  little  more  than  half  a  degree. 
Such  figures  as  theae  tell  a  very  sti-iking  tale. 

Briefly,  then,  Chart  I  shows  an  increase  in  the  nnmber 
of  adraissiong,  a  deereasB  in  the  number  of  febrile  cases  and 
particularly  of  septic  cases,  end  a  dimiuutioa  iu  the 
amoant  of  fever,  not  only  relative,  but  abeolnte. 

But,  as  will  be  gathered  from  the  table,  the  number  o£ 
patients  admitted  month  by  month  presents  snch  consider- 
able variation  as  to  render  comparison  of  one  month  with 
another  a  matter  of  difHculty.  Instead,  thcpofore,  of  resting 
conteut  with  the  crude  figures,  I  have  constructed  a  sepa- 
rate series  of  charts  based  on  percentages. 
Chart  IX  (p.  28ob)  ia  divided  into  four  parts. 
The  p]RST  DIVISION  gives  the  percentage  of  patients  in 


TUVKR    m   CHTtiDBED. 


229 


which  the  ti?mperature  roue  above  lOO"  F.,  aud  the  per- 
ccntnge  of  patients  who  were  afifected  with  septicomift  and 
polric  in  flam  dial  iou. 

In  each  case  the  tempemture  was  titben  (by  mouth) 
thrtvughuat  the  patient's  stay  in  hospital  every  four  hours, 
night  BH  well  ob  day  nolesa  she  happened  to  be  aslcep> 
and  any  rise  above  I00°  F.  is  reckoned  as  fever.  And 
whcrerer  the  line  joining  two  consecutive  observations 
orosse.s  nny  section  of  the  cliai-t  above  thia  level,  that 
section  ia  inoluded  in  the  fever  category,  as  if  observations 
had  been  made  coatinuoualy  iu  every  part  of  that  line. 

I  may  tiike  occBBion  hero  to  point  out  that  had  the  tbor- 
mometer  beau  cinploycd  lose  assiduously  u  large  proportion 
of  the  pyrpiin  cft<es  would  have  been  climinnted,  whorcae, 
nnder  the  plfin  adopted,  are  iuelud^d  all  the  slight  trausi> 
tory  rises  of  temperature  (to  100*2''  ov  thei-eabout)  which, 
though  indicated  by  the  thermometer,  are  as  a  rule  un- 
attended by  appreciable  Bymptoijis  of  illness.  TheRe, 
indeed,  form  by  far  the  larger  portion  of  the  pyrexia  cases 
which  have  come  under  obnervatiou  during  the  last  Bre 
years  dealt  with  iu  the  charts. 

Unless  this  fact  be  taken  into  consideration,  the  im- 
provement as  indicated  by  the  first  division  of  Chart  II 
would  bo  greatly  discounted.  For  it  represonts  the  per- 
oentage  of  puorperto  who  bad  pyrexia  without  taking  into 
eon  side  ration  wither  the  hoight  or  the  duration  of  the  fever, 
and  therefore  are  included  all  those  Kligbt  tranbitory  rises 
to  which  I  have  alluded. 

But,  even  taken  eh  it  standi,  a  marked  improvement  is 
manifest. 

For  during  the  6r8t  eighteen  months  the  number  of 
deliveries  folluwcd  by  pyrexia  generally  exceeded  70  per 
cent.,  and  oftou  ruochcd  an  high  &a  96  per  cent.  Duritig 
the  first  four  months  of  1884  the  figures  declined  from 
SI  per  cent,  to  65  per  cent.  Then  occurs  a  wmarkable 
drop,  and  from  that  time  onwards  50  per  cent,  ie  i-arely 
exceeded.  In  general  terms  it  may  he  said  tliat  prior  to 
Hay,  1864>,  83  percent,  of  the  patients  confined  had  some 


280 


PEV'ICB    IK    OHILDBRD. 


rise  of  tempemtiirc  nbove  lOO'^  F.  duriug  the  ])uorperinm, 
but  tliflt  after  that  date  40't>  per  cent,  were  similaply 
affectfd — in  otlier  words,  that  ike  uumber  of  laboars  fol- 
lowed by  pyrexia  was  more  tliau  halved. 

But,  in  addiiioii,  ilie  first  division  of  Chart  II  gives  the 
percentage  of  patieuta  who  were  affected  with  septicBOraia 
and  pelvic  inilammation. 

This  ahowa  that  during  the  first  eighteen  uontha  the 
proportion  of  deliveries  followed  by  fjepttcesmia  and  polvic 
inflaraination,  thongh  varying  ffreatlj,  never  fell  below 
22  per  cent.,  and  reached  aa  high  as  69  per  cent.,  but 
during  the  first  four  months  of  1884  declined  from  31  per 
ceist.  to  10  per  cent.  Of  the  whole  number  of  patients 
delivered  in  the  hospital  before  May,  1884,  no  leas  than 
40  per  cent,  were  attacked  with  Beptica^uiia  and  pelvic 
iiitliiiuTnation,  compared  with  less  than  2'5  per  cent,  after 
that  date. 

And  bere  I  may  take  occasion  to  mention  that  a  certain 
atnoiint  of  doubt  necessarily  attaches  to  the  septic  data, 
owing  to  the  diBicuUy  in  deciding  as  to  the  precise  cauae 
of  the  fever  in  aoine  of  the  cases.  But  as  this  difficulty 
occurred  mainly  in  the  early  months,  and  applies  chiefly 
to  cases  of  slight  intensity — to  cases  of  saprMmia,^! 
have  no  doubt  in  my  own  mind  that,  even  when  allowance 
is  made  for  t.onte  of  the  fever  from  other  causes  being 
masked  by  Bepticteniia,  and  consequently  included  in  that 
category,  the  improvement  under  thie  bend  wns  actually 
rather  greater  than  is  shoi^T  in  the  chart.  It  may  alfio 
be  noted  that  all  cases  which  presented  signs  of  inflamma- 
tion in  tlie  piclvis,  wliaicrer  vieiv  may  be  held  as  to  the 
nature  of  swch  in  iiidividnsl  instances,  are  tiicluded  in  the 
septic  category.  At  the  same  time  I  may  add  that  no 
doubt  whatever  attaches  to  the  genernl-pyroxia  data, 
which  are  based  on  facts  involving  no  diagnostic  skill. 

The  8KC0SD  DIVI8I0S  gives  the  average  daily  percentage 
of  patients  in  hospital  with  pyrexia,  and  with  septicemia 
and  pelvic  inflammation. 

A  momeot's  reflection  will  show  in  what  respect  this 


FETXB   IN    CBTID'BKD. 


differs  from  the  preceding  divJBion.  In  tlie  first  division, 
tlie  percentage  of  patients  wlio  were  affected  with  fever 
iitull  witii  septic  fever  was  alone  represented  ;  but  this, 
representing,  as  it  does,  the  nverage  daily  percentage  of 
pntients  in  hospital  suffering  from  pyrexia,  takes  into 
account  not  only  the  proportion  of  fehrilo  to  non-febrile 
cases,  and  of  septic  to  oon-Bcptic  cases,  but  also  the  dura- 
tion of  the  fever,  And,  as  I  shall  presently  show,  simul- 
taneously with  the  diminution  in  the  number  of  fever 
cases,  the  duration  of  the  pyrexia  in  such  cases  ag  were 
afFeotttd  with  fever  became  considerably  less.  The  net 
resnit,  therefore,  as  given  in  this  division  of  the  chart, 
is  correspondingly  greater — the  improvement  which  tm>k 
place  appears  to  Htill  greater  advantage. 

On  reference  to  the  table  [p.  2-3od),  it  will  be  seen  that 
during  the  first  eighteen  months  the  average  daily  nnmber 
of  patients  in  hospital  suffering  from  fever  generally  ex- 
ceeded yO  per  cent.,  and  was  often  as  high  an  50  per  cent, ; 
that  during  the  first  four  months  of  1884  the  oorrespondiiiig 
fi Inures  declined  from  32  to  20  per  cent.,  and  that 
subsequently  10  per  cenl.  was  Beldoin  exceeded.  True, 
the  drop  does  not  appear  so  striking,  because  some  of 
the  patients  admitted  during  April  carry  their  days  of 
fever  into  the  following  month.  Nevertheless  the  rapid 
fall  is  suggestive. 

lu  general  terms  it  may  be  said  that  prior  to  May, 
1884,  the  daily  number  of  pntients  in  hospital  who  were 
affected  with  pyrexia  was  yO  per  cent.,  against  8  percent, 
after  that  date  ;  or — to  put  the  matter  in  another  way.^ 
this  date  forms  the  boundary  liae  between  an  attack  of 
fever  extending  oveir  more  than  a  third,  and  a  pyrexia! 
attack  lasting  less  than  a  twelfth  part  of  each  pAtient's 
stay  iti  hospital. 

Tbe  improvcmont  in  this  respect  is  emphasized  by  the 
fact  that,  originally,  more  often  than  not  it  was  found 
necessary  to  keep  the  patient  in  hospital  for  some  time 
after  the  fortnight  had  expired,  in  some  cases  for  perhaps 
30,  40,  or  even  as  much  as  50  days,  too  ill  to  be  moved  ; 


282 


niVIB    Iir    CBILDBET>. 


bat  now  for  &  patient  to  receive  her  discharge  at  a  later 
dato  than  tlie  fourteenth  day  has  become  quite  the  eicep- 
ttoii.  Moreover,  in  order  to  guard  against  the  possiliility 
of  any  illueaa  bt'iug  uvcrlookid,  every  patient  on  lenving 
the  hospital  is  provided  with  an  addressed  post-card  to  be 
returned  at  the  end  of  a  month. 

In  this  division  of  the  chart,  also,  the  average  daily 
percentRge  of  patients  who  were  affacted  witt  septic  fever 
ia  separately  repreaeutod.  The  daily  number  of  patients 
in  hospital  auffeiiug  from  septic  fever  before  May,  1884, 
averaged  27  per  cent,  of  the  whole  (the  number  varying 
dnring  the  first  eighteen  months  within  lU  per  cent,  on 
either  side  of  that  amouut),  agaJDst  I'd  per  cent,  after 
that  date,  when  the  curve  exceeded  10  per  cent,  in  oue 
montli  only  (and  that  happened  iu  May,  1884,  from  illness 
coutvacted  dmiug  the  previous  month),  and  often  for 
months  togcthei"  remained  at  zero.  In  this  respect  also 
the  improvement  is  well  marked  at  the  beginning  of  1884, 
The  THIRD  DirtsiOH  gives  the  average  daration  of  the 
fever  ill  days, 

This  i&  calculated  for  the  oases  of  febrile  illness  only, 
not  for  the  total  nnmhor  of  patients.  The  shortened 
dnration  of  tlie  fever  is  here  separately  represented. 

Before  May,  lSy4,  cases  of  fever  usuiilly  per«isted  for 
at  least  five  and  often  as  much  as  ton  days,  but  after  that 
date  the  average  never  exceeded  five  days,  and  as  a  rule 
■was  much  below.  Speaking  in  general  terms,  therefore,  it 
may  be  said  that  fever  which  originally  persisted  for  at 
least  a  week  now  ceased  at  the  end  of  lliree  days.  In  this 
respect  also  some  improvement  is  seen  to  have  taken  place 
during  the  months  which  immediately  precede  the  obovc- 
nicntioned  date. 

But  the  proportion  of  febrile  to  non-febrile  cases  and 
the  duration  of  the  fever  aa  yet  have  been  alone  taken 
into  account.  It  remains  to  consider  the  height  of  the 
fever. 

The  FOURTH  siYieiON  gives  the  average  daily  rise  of 
temperature  for  each  pyrexial  patient. 


ri^VKR    IN     CBIIDBKD. 


2S3 


Here,  again,  a  corresponding  improvomeTit  is  manifest, 
tunouuting  to  a  redaction  of  nearly  1"  F,  For  daring  the 
months  whicTi  precede  May,  1884,  the  fever  ranged  from 
10-2°  to  103°.  bat  after  Hiat  date  rarely  reached  102** ;  and, 
iu  fact,  declined  from  I02"n''  to  I01'6*'  P.,  aa  givou  by 
tlic  collective  averages  for  eacb  period.  No  appreoiablo 
improvomfat  ia  this  reepeot  is  observed  daring  the  montha 
Wfhicb  immediately  precede  tha,t  date. 

Each  division  of  Chart  11,  theoj  is  seen  to  agree  in 
pointing  to  an  improvement  dating  from  May,  1884-;  and, 
farther,  sbowfi  that  ibifl  improvemout  took  place  to  soms 
extent  in  the  months  which  immediately  precede  that  date. 

Considered  aa  a  whole,  Chart  II  proves — 

That  not  only  has  the  propnrtion  of  fehrtle  to  non-febrile 
cases  diminished,  but  ali^o  the  jiroportion  of  septic  to  non- 
septic  caHcs  ha»  at  the  same  time  Mitt  more  markedly 
ditniniahcd,  and  for  months  together  such  ca&os  have  en- 
tirely disappeared  ;  and  thot  simultaneously  the  duration 
of  the  fovcr  has  been  shortoned  and  its  height  diintui&faed. 

Chart  III  (p.  235c)  expreBftes  these  results  in  a  con- 
dcnacd  form. 

By  maltiplying  together  the  percentage  of  labours  fol- 
lowed by  pyrexia,  the  duration  (in  days),  and  the  height 
(in  degrees  above  100''  F.)  of  the  fever,  it  is  possible  to 
present  a  fairly  correct  index  of  the  condition  of  the 
hospital  for  each  month  throughout  the  seven  yoare.  Sy 
moving  llio  decimal  point  two  places  to  the  loft  the 
average  amount  of  pyrexia  from  all  causos  per  patient  is 
derived.  The  figures  thas  obtained  arc  very  inslroctive. 
By  this  means  the  variations  which  occurred  are  presented 
in  an  amalgamated  form.  For,  being  the  prodnot  of  tKe 
first,  third,  and  fourth  diviBions  of  the  preceding  chart 
reduced  to  unity,  it  takes  into  account  not  only  the  pro- 
portion of  febrile  to  non-febrile  cases  and  the  duration  of 
the  fflvcr,  tut  also  the  height  of  the  tenipcrnturo,  and 
therefore,  as  au  index  of  the  condition  of  the  honpital  for 
each  month,  is  not  to  be  surpiusKod.  But  as  it  often 
buppeued  that  patients  admitted  towards  the  close  of  one 


234 


TEVBR    IN    CatLDBKD. 


month  had  little  or  no  fevRr  ontil  the  following  month, 
and  that  when  the  attack  was  proloDged  the  fever  was 
continued  into  the  month  follovitig  admission  and  even 
later,  this  only  represents  approximately  the  fever- rate  for 
each  patient  admitted  during  the  laouth  to  which  it  refers. 
It  has,  therefore,  been  placed  nnder  the  heading  of 
*'  ArpsoxiuATK  PBVBR-E4.TE."  This  IS  represented  in  Chart 
III  in  outline  ou]y  (white  on  black  ground  and  black  on 
white  ground). 

The  true  ^kve&'Rate — that  le  to  say,  the  average  amount 
of  pyrexia  from  all  causes  (in  days  x  degrees  above 
100°  F.) — for  ench  patient  admitted  during  each  month  is 
given. 

By  referring  to  the  t«ble  [p.  235d),  it  will  be  seen  that 
during  the  first  year  and  a  half  the  amount  of  fever  which 
followed  upon  each  labour  presented  considerable  variation 
month  by  month,  but  that  tt  was  invariably  great — the 
lowest  figure,  as  given  by  the  true  fever<rate,  approaching 
6  degrees,  atid  the  highest  number  almost  reaching  25 
degrees.  Then  follows  a  noteworthy  declension.  Through- 
out the  last  five  years,  with  the  exception  o(  occasional 
elight  relapses  (in  which,  however,  G  degrees  was  once 
only  exceeded),  a  point  varying  but  little  on  either  side  of 
1  or  2  degrees  has  been  fairly  maintained.  These  figures, 
when  reduced  to  general  teriaa,  indicate  that  prior  to  May, 
1884,  each  patient  admitted  passed  through,  on  an  average, 
17  degrees  of  fever  during  the  puerperium  against  1  degree 
after  that  date.  This,  by  way  of  example,  may  be  takoo 
to  mean  that  every  labour  was  followed  by  tomporaturo 
rising  daily  to  100°— 101°  P.  for  seventeen  days,  of  lOl** 
— 102"  for  eight  or  nine  days,  of  103° — 104*  for  four  days 
or  rather  more,  or  by  a  similar  amount  of  fever  otherwise 
distributed;  but  that  after  May,  1884,  a  slight  rise  of 
100" — 101*  F.  occurred  for  one  day  only — trulya  ranrvel- 
lous  difference. 

It  may  be  noted  that,  when  the  cases  of  sovcro  and 
prolonged  UIdcss  are  few,  the  true  and  approximate  fevor- 
rates  very  nearly  coincide. 


^          286i> 

1 

July.   A""!'. 

May, 

June, 

July. 

A 11^., 

Sept., 

Oct.. 

Nov., 

D«c., 

18S3 

1385 
13 

i8»e 

ICJHS 

18b6 

1H&5 

1885 

188^      1885     1885  1 

ri) 

113 

IS  '   so 

IS 

IS 

IS 

U 

13 

21 

« 

17 

IS    1     18 

16 

22 

20 

85 

IS 

16 

(2) 

27 

BO 

S6    1     J)S 

27 

3T 

38         SR 

28 

40 

70:iT<i 

H 

•-ys.\  50i'i".i  52''i;ii  44  v  '-i  40-;it"  47  -itiH  30  :■  J.'-  46  i-'^  60'xtu| 

^^^^pezy-ii;^:!  ii sm  auiwi ij^bp^ :■>!>■' pa  oi'-^p'/i lya  tiuivt b^i>7\  4U <-"■•<. 

16) 
(0) 

^^^Bisaftii;;tai  us  itsaoiamxiiaaos  flBaslliM  B-ais  lloo?iflaif, 

^^^^7{67i^3ti646o-i'88  ]«!>8?  100  66001  90  370  88  w:>  91-4^0  88  ti!)2  SlGS-i 

(7) 
(8) 

8  «S4'  (307 

4070   315UI  4M3:  g-iSft   3-222 

3-818    3-6L5|  41(i6 

^^^^B6 

13'i<3aiiVioo 

4(W2   3:!«r,'  6-119   3-354-  g'CGGi  3-o%'  3-333  5-354! 

^^^^^F^ 

2fil8 

J'732 

4H;6,   1-656    3-43l|   1-923    1-OGa 

1            1 

3-283    31S7    119; 

(10) 

01) 

^^^HMJIR-OfM 

IV 1 00 

4S07    2S7S     6S22    2-702,    l-|i3i 

2-fl6S    3571    4-02.''-> 

18-777  ll5fif 

5730    2'0:i2.    5-81-1-'   2*02"    2-421!    l-750    6SR2    2'tHKi 

.(12) 

(laj 

»            212            2             1              i             I|l             1             I 

^^^^■wi'AC)(;:^iiai'4',(t<i'  t-HM  ft-2if;t  a-rtw'  S'Toa  ft(>3i 

2*777    3*571    2-''<* 

(1-0 
(ISl 

^^^■dASa  10l?1<>;a    Tasil    l-ilKii    fi-77a!   R237    ni7i 

3435    1-9S3    1-09^ 

^^^■H'  is  :^To  11'  'MK)!  U  'Jtil    0  Ui 

4GdG    0-213    0  U7i  0;>72    Q  3S7    QSCO 

(HI) 

1 

Jan., 

Bc-t.. 

Nof..     Dec, 

Jan., 

Fell.,  Marcli 

April, 

Miiy, 

Juiip, 

1S87 

1&8S 

LSSa     1898 

1889 

1S88     1689 

1889 

ISJSa 

18S0 

0} 
(a) 

(3) 

(-11 

IS 

21 

S 

0 

7 

8         U           6 

17 

10 

^^^HEi 

20 

Si 

93 

80 

35 

87    1    89        S7 

19 

i)3 

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42 

35         bO         33         3<i 

43 

37-O0O  44-t;t";ij  iS'S^i  23'iJ7i' 

16  fill'".  22  sriT  22000 18-I8i'47'222l23'3'i5 

^^^Hk:H 

S2'  oL"  >  5S-^a:i  84  "i  j  76'  H23 

83333  77  lJL'780it.  81«IK52t;7'76  7+j 

(5) 
(«!1 

^^^^KHi 

10fi83  g'"*'-  2P23  3Mai 

3  503    3lfi4   2fW.    5  Ma 

8  78fi   6 15S 

^^^^B^'' 

89 ;in> 9ftw5j 97i'7-* 96  I'M 

96'4:j696  a3o^97  00 1 94  itib 

91 2 13  93*  ^-t> 

('J 

(a) 

1 

4-l(tli|  ('904    Zi'iW    2'i2-i 

3 *U2    rS78    Ifise,  4'66fl 

2--viv  2*700 

S-ll!)    S 129    0'700    1120 

0^35    0760    0'7-H    2  50O    2000 

1-lflf 

^^^^H5V 

]-M»    1-590|   l-aia    1750 

1318|   1-«W    1-S77|  2671>   WU 

l-fiM 

{10) 

(in 

1 

^^H-17 

2;iW    $155   0^3H    0'*"' 

Onw   OOO"  O--"".''  2''-!7a    1-72'.!'  yovi 

^^^■n 

l:t,-,i    a.i^":i.  0'51^   0;ii7 

0"TI    06".li    0'«73    \'>W    l-HUH    0  *^™ 

(12) 
(13) 

1 

1         'ail          0 

0         1     1     0         0     1     0 

D 

^^^H?^ 

3125  14-3*7!  2B64    Oi« 
6'3(i'i    ^HfiG    0551     OlOl 

OOWI    2i77;  0*000    0-000    0000 

0*0«f 

(14) 

^^^^■&3 

O'ooo  0*rt3fi  0000  0*000  O''*"" 

0-oa 

(15) 

1 

^^^H" 

0-531    I>'739    0*173    O't'l 

Oooo    O-in'  0000   0'"*»  0*E»<K 

1 

O^Mt 

(IS) 

^H 

FEVJCR    Ol    CHILDBSP. 


236 


The  BEPTic  RATE — that  is  to  say,  the  average  amount  of 
pyrexia  due  to  aepbicffimia  and  pelvic  indatnmatioti  (in 
days  X  degrees  above  100"  F.) — for  each  patient  admitted 
daring  each  mouth  is  also  given. 

On  referring  to  the  table  it  will  be  seen  that  the  septic 
rale  during  the  first  eighteen  mouths  on  one  oocasiou 
almost  reached  23  de^gi-ees,  and  rarely  fell  below  10;  that 
it  declined  perceptibly  at  the  beginning  of  1^84,  and  after 
May  of  that  year  rarely  rose  above  3  degrees,  and  was 
often  reduced  to  zero  or  to  a  fraction  of  a  degree  for  months 
al  a  time.  In  general  tei'iiiH  it  may  ho  said  that  the 
septic  rate  fell  from  13  to  leas  than  half  a  degree. 

This  chart  further  demonstrates — 

(1)  That  the  dfcliiie  in  the  general  fever-rate  has  in 
the  main  resulted  from  docliue  in  the  septic  rate. 

(2)  That,  though  occasional  slight  rises  have  occurred 
during  the  last  Sve  3'enr3,  the  general  tendency  has  been 
towards  improTement,  not  only  in  the  general  fever-rate, 
bnt  aUo  in  the  septic  rate ;  and  that  when  the  general 
fever-rate  bns  risen,  it  has  in  the  main  resulted  from 
incrense  in  the  septic  element. 

Three  out  of  the  four  propositions  set  down  at  the  out- 
set hare  now  been  considered  in  detail  (see  p.  227  nufra). 

Before  proceeding  to  describe  the  service  of  the  hospital 
and  the  changes  which  have  been  effected  in  it,  it  will  be 
advisuble  to  inquire  more  particularly  into  Hie  nature  of  the 
illness  prevailing.      This  will  occupy  the  followmg  aectioa. 


2S4 


VEVER    IN    CBILDUED. 


11.  The  death-rate  and  the  nature  of  the  iltnef^n  prevailing  j 
decrease  in,  and  iemporarjf  abolition  of  septic  cages. 

(RewiVvA  Decemha  lOtli.  ISH'X) 

*  [Ahstracl.) 

A  Tabulab  Statement  ia  given  of  tin;  naoro  severe  cubcb  of 
ilhioee  uuiter  tbrc^e  headB,  wliich  inclucle  all  the  cases  (I)  which 
were  defaitif'l  beifond  three  toecks,  (2)  which  were  tramferrcd  to 
ot}icr  hofpilalit,  (vml  (3)  whidi  ended /alallij.  A  ehort  accuuut  of 
each  of  the  deatha  is  giveD  id  a  Becokd  Of  Fxtal  Cases. 

By  t-hiK  lu^mis  the  indiieuc?  of  the  dimiuution of  febrile  illness 
on  the  d€ath-rat«  iti  shown. 

The  natuTV  of  the  iltutisB  falliu^  under  ench  bead  is  tLoulytied 
ID  buru,  A  lie/  of  reference  to  the  cAse  DUubers  ia  emh  sfiries 
is  ndi^gd  to  Chart  III,  in  orduv  tt>  brlug  the  cases  of  eev-ore  Uhivsa 
au<l  the  fever-rato  into  mutual  relation  Cor  each  moath. 

The  general  fever-rat*  and  aejitic  rate  as  given  in  Chart  HI, 
and  the  severe  eases  of  illuees  as  given  in  the  Tabular  Stttti-- 
ment,  talieu  toother,  iadii.-ate  with  some  degree  of  preci^ioa  the 
Btato  of  the  hospital  at  different  pi^riods. 

May,  1884,inarkK  an  important  epoeh  in  the  hospital's  history. 

The  condition  of  the  hospiUil  WforL'  and  after  that  date  la 
comuieutcd  upon  and  is  snnirimrieed  in  Tabi-k  II,  wiieriftl  atten- 
tion being  drawn  to  the  ubru^jt  detlino  <tS  eoptic  illucss  which 
occurred  at  that  time. 

This  Table  shows — ■ 

T/iat  the  deatk-ralt:  from  all  catuex  foUoKf-d  !hr.  ihcHne  in  the 
general  fever-ratp  ,-  atid  thai,  as  in  the  oaa  aaac  Ihti  irnprorrm/tnt 
reimlied  in  the  main  frovi  drcrcasr  in  tha  tt'imfjer  and  eeieriti/  of 
caert  affected  with  teptieetmia  and  pelvic  inflammation,  to  in  tha 
olhrr  the  decline  tM»  main!!/  wrought  by  decrritte  in  and  trntipo* 
rary  ahoUlion  of  the  septic  eiemenl. 

Cunsidemblu  pruxreas,  as  »liow»  \>y  the  ilecreasing  di-a.t1i- 
late  (tht:  only  criterion  available  for  that  distant  dato),  had 


rSTKB   IN    CHILDBED. 


237 


been  made  in  tlie  eame  direction  ^irior  to  tbe  commeDc^incDt  o£ 
tho  sepN^QQiEil  period  now  under  conaiddrntion,  but,  as  far  att  is 
known,  no  stich  compnratiye  imtuunitjr  from  septic  illneBS  bad 
been  hitherto  attained. 

Thd  continued  decrease  in  tie  death-rate  and  tbe  ateadj 
diminntion  of  febrile  iUuess,  and  especially  of  septic  illneea, 
indicate  thnt  improvifmcnt  Is  still  ^oiag  on. 

In  the  foUuvriu^  sectiotie  tli*?  service  of  tb'e  hospital  and  tho 
changes  which  have  been  effected  in  it  will  be  considered.  The 
coincidence  of  these  clangs  with  varifttiona  ia  tbe  condiUon  of 
tlie  hospital  will  be  triioed. 


In  this  section  I  shall  show  to  what  extent  tho  decrease 
in  the  atnonnt  of  fobnlo  illocsg  offootod  tbo  deatb-ratc. 

I  would  in  the  first  place  point  out  two  ways  in  which 
Chart  III,  when  taken  by  itself,  fails  a»  a  perfectly  correct 
index  of  tbe  total  amount  of  morbility.  I  refer  to  those 
patioDte  who  died  in  the  hoBpital,  and  to  those  who  were 
trtkuaferred  to  other  hospitaJH  on  account  of  prolonged 
illneee. 

A  Tabular  Statement  (p.  244)  ia  given — 

(1)  Op  all  reE  casks  im  wtiicn  it  was  pound  meckssary 

TO    DBTAIK    THE    PATIHNT    FOR   A   LOIfGKK    PEJtIOB   TUAN   THREB 
WIEK8  AFTKK   DKLITIKY. 

(2)  0?  ALL  THE  CASKS  IN  WHICH  THB  PATIKKT  WAS  TKAK8* 
TKBRBD  TO  AMOTHBK   HOSPITAL. 

(3)  Of  all  TBS  CABIH  WHICH  BHBKD  FATALLY. 

Tho  position  which  they  sererally  occupy  upon  the  chart 
is  indicated  by  the  corresponding  and  distinctive  nurabor 
of  each  series  [see  Chart  111,  p.  235o). 

These  categories  include  the  more  serere  forms  of  ilU 
nesB,  but  without  some  Riich  notification  the  soeond  and 
third  would  not  be  popresented  to  the  full  extent  in  the 
chart,  for  tho  fever  in  the  one  case  is  often  cut  short  by 
death,  and  in  the  other  breaks  off  when  the  transfer  of 
the  patient  is  efTected.  As,  however,  after  May,  1884, 
both  tbe  death-rate  dccrcanoJ  and  tbe  number  of  cases 
which  it  wtts  found  necessary  to  transfer  diminished,  the 

TOb.  xxxu.  17 


288 


FETEIi    IN    CniLUUED. 


improvement  represented  by  tlie  cliart  is  in  no  way  diB- 
counted,  but  rtither  the  reverse. 

Tliis  becomcB  Btill  more  ondent  wliea  the  catare  of  the 
illcesa  is  taken  into  coaaideration. 

Glance  for  a  moniient  at  the  nature  of  %ho  fifteen  fatal 
oases.  A  fihort  aocount  of  each  will  be  found  in  the 
appended  Beeord  of  Fatal  Cams  (p.  252).  They  form  :l 
soitalilo  pegj  upon  wliich  to  La.ag  tliB  remarks  wbicli  I  am 
about  to  make  with  regard  to  the  character  of  the  ill- 
DBBaea  which  prevailed  prior  to  and  snbsequent  to  May, 
1884. 

Preyious  to  that  date,  sis  deaths  took  place  among  612 
patients  admitted,  giving  a  mortality  of  very  nearly  1  per 
cent.,  yiz.  1  in  102,  All  of  thoae  cases  arc  essentinlly  septic 
in  character : — (!)  Pyometritia,  pelvic  peritonitie,  and 
septic  phlebitJB  ;  (2)  severe  traumatic  inflammation  ending 
in  abscess  and  purulent  peritonitis ;  (3)  general  septic  in- 
fection ;  (4)  septic  phlebitis  and  acute  endocarditis ;  (5) 
traumatic  hiematoma  ending  in  abscess,  pyolymphangitis, 
perimetritis,  and  paranietnfcia ;  and  (C)  pyometritis,  septic 
phlebitis,  and  acute  endocarditis. 

After  May,  1884,  nine  deaths  took  place  among  2150 
pEitients  admitted,  giving  a  mortality  of  little  more  thaD 
0'4  per  cent.,  or  I  in  239,  Two  patients  died  from  ad- 
vanced pulmonary  phthiaia,  two  others  from  eclampsia, 
one  from  htemorrhage,  and  one  from  mercurialism  and 
morphiniBm  combined,  in  all  of  which  &eptic£Bmia  played 
no  part ;  one  succumbed  to  septic  phlebitis  and  genei-al 
pyaeuiia ;  one  to  sloughing  ot  the  soft  parts  and  parametritic 
abscess  following  severe  iustrumeutal  labour,  and  one  to 
hospital  gangrene.  With  the  siugle  exception  of  one  of 
the  advanced  phthisis  cases  (concerning  the  nature  of  which 
there  could  be  no  doubt),  all  of  these  last-mentioned  cases 
were  verified  by  post-mortem  examination. 

That  deaths  from  an  affection  so  prevalent  an  pulmo- 
no-ry  phthisis  or  bo  fatal  aa  eclampsia,  in  BssocJatiou  with 
childbirth,  will  from  time  to  time  occur  among  puerperal 
patients  is  only  to  be  expected,  and  cannot  be  guarded 


PETER    IN    CHILDBED. 


230 


against  vhea  no  selection  of  patients  ia  ma^e,  T)ut  may 
rather  be  anticipated  in  au  institution  to  which  the  laore 
serioua  cases  natarally  gravitate.  The  point,  therefore,  to 
which  I  would  direct  ftpecial  attention  ia  not  the  evidence 
of  such  casea,  bat  the  fact  that  while  eix  deaths  occurred 
from  septic  illness  among  600  patients  before  May,  1884, 
three  deaths  only  can  be  attributed  to  septic  influence  iu 
more  than  2000  confinements  which  followed  that  date— 
a  mortalitf  bat  one>  seventh  part  of  the  previons  death- 
rate. 

Moreover,  the  instances  of  severe  and  prolonged  illneea 
which  necessitated  transfer  to  other  hospitalB  tell  a  pre- 
oiaely  similar  tale.  These  include  !5  cases  of  scarla- 
tiQa  which  were  sent  to  the  hospital  oE  the  Metropolitan 
Asylums  Board  at  Stockwell,  not  on  acconnt  of  the  severity 
of  the  ilinesB,  but  in  order  to  prevent  the  spread  of  in- 
fection to  other  patientB.  Omitting  these,  prior  to  May, 
1864,  18  were  transferred  on  account  of  severe  or  pro- 
longed illness,  against  10  subsequently,  gi^'ing  &  ratio  of 
1  ia  34  against  1  in  215.  And  here,  again,  it  is  found 
that  septic  poisoning  played  a  very  subsidiary  part  after 
May,  1884. 

For  before  that  date,  among  tlie  cases  transferred  may 
"bo  reckoned  twelve  of  pelvic  inflammation  (of  which  two 
ended  in  abscess,  one  of  them  being  complicated  by -mania, 
one  was  associated  with  erysipelas,  and  anotlior  with 
typhoid  fever  and  pleurisy  ;  one  with  acute  nephritis,  and 
one  or  two  with  uystitis)  and  two  eases  uf  general  septic 
poisoning ;  one  of  remote  abscesses  of  doubtful  urigin, 
one  of  doable  phlegmasia  doleos,  and  two  of  acute 
mania. 

Uut  after  that  date,  two  cnses  only  of  pelvie  inflamma- 
tion appear  (both  undergoing  resolution),  the  remainder 
comprising  one  of  acute  mania,  one  of  eclampsia  followed 
by  mania,  and  one  of  eclampsia  asaocititod  with  acute 
nephritis  and  followed  by  otorrhosa  and  meningitis,  one  of 
ohronio  nephritis  and  ascites,  one  uf  chronic  nephritis  and 
thrombosis  of  the  internal  saphenous  vein,  one  of  cancer  of 


240 


KKVlilt    IN    CQILDUBD. 


fclie  nteruB,  one  of  cancer  of  the  rectum  with  reot4>TagiDBl 
fiBtiila,  and  cue  of  veaico- vaginal  fistula. 

Turning' now  to  the  cases  which  it  was  found  necese&ry 
to  detain  beyond  three  weeks  from  the  date  of  delivery, 
the  same  facts  are  proclaimed.  They  uerve  to  empbasiae 
the  proof. 

Prior  to  May,  1884,  fifty-fivo  such  cases  are  recorded. 
They  include  thirty-eix  iuatancea  of  pelvic  inQaiuinatioii— 
perimetritis  and  parametritis  (the  ma.jority  accompanied 
hy  exudation,  of  which  five  ended  in  abscess ;  two  others 
being  associated  with  mammary  ab^oess ;  two  of  the 
former  and  oae  of  the  loUer  suppurating  casOft  being 
complicated  by  Toania  ;  one  was  aagooiated  with  gastritis  j 
ono  or  two  with  cystitis;  one  with  iicute  nephritis;  one  with 
pleuriHy ;  one  with  ecurlatinn.,  acute  nephritia,  and  pleurisy ; 
and  one  with  typliuid  levar  and  plouui&y),  together  with 
BIX  cases  of  general  septic  poisoning,  of  which  three  ended 
fatally  ;  three  additional  cases  of  mammary  abscess;  two 
additional  of  cystitis;  and  one  each  of  double  phlegmasia 
dolens,  of  remote  abscesses,  of  acute  gastritis,  of  glyco- 
8uria,  and  of  general  weakness.  Two  cases  which  were 
probably  scarlatinal  (one  being  associated  with  pneumonia, 
mania,  and  doubEe  mammary  abscess  ;  the  other  with  late 
perimetritis],  and  one  other  of  an  obscure  nature,  complete 
the  list- 
After  May,  1884,  the  record  laoludea  but  twenty-six 
Buch  cases.  Witness  the  difference  also  in  their  nature 
— four  oases  of  pelvic  inflammation  (one  being  associated 
with  single  and  one  with  double  phlegmasia,  but  all  under- 
going resolution),  one  case  of  sloughing  of  the  soft  parts 
associated  with  paramolritic  abscess  whicb  ended  fatally  ; 
three  cases  of  mammary  abscesB;  two  of  cystitis;  four  of 
thrombosed  veins  in  the  lej^ ;  one  each  of  chronic  bronchitis, 
of  BCiite  plenrisy,  of  intestinal  irritaliun,  of  nephritis,  and 
of  eclampsia  associated  with  acute  nephritis,  and  followed 
by  otorrha>a  and  meningitiH ;  two  of  recto-vaginni  fistula 
{one  being  associated  with  cancer  of  the  rectum)  ;  and  one 
of  vesico- vaginal  fistula.      One  other  patient  was  detained 


FETSR    IH    01 


S4I 


on  account  of  weakneBs  resulting  from  ante-partiim  htomor- 
rhage,  aud  ooe  on  the  iafant's  account.  In  tie  two  re- 
mnining  c&sos  the  nature  of  tbo  Illness  was  aDdetermined. 

It  will  be  observed  tha-t  occasionally  the  saiUQ  case 
appears  in  more  than  one  category. 

The  facts  givBn  in  this  statement  are  very  striking  when 
allowance  is  made  for  the  diflerence  in  the  number  of 
admissions  daring  each  of  these  periods. 

The  condition  of  the  boepital  before  and  after  May, 
1884,  ia  auramarised  in  Table  II  (p.  2(33). 

This  tuble  shows — 

That  the  death-rate  from  alt  causes  followed  the  decline 
in  the  general  fever-rate,  aud  that,  as  in  the  one  case  the 
improvement  resnlted  in  the  main  from  docroaso  in  the 
number  aud  sBverity  of  oases  aflocted  with  septicaemia  and 
pelvic  inSammation,  so  ia  the  other  the  decline  was  mainly 
wrought  by  decrease  in  and  temporary  abolition  of  the 
septic  element. 

Conaidcrable  progreaa,  an  shown  by  the  decreasing  death- 
rate  (the  only  criterion  available  for  that  distant  date), 
had,  howerer,  been  made  in  the  same  direction  prior  to 
the  commenoement  of  the  septennial  period  now  under 
oonaideratioD,  but,  ns  far  as  is  known,  no  auch  compara- 
tive immunity  from  septic  illness  had  been  hitherto  at- 
tained. 

Conseqnently  the  improvement  which  has  now  taken 
place  stands  out  in  greater  prouiiuenco  Mtill  wht-u  the 
aeptennial  period  now  completed  is  compared  with  the 
past. 

Wo  need  but  took  back  a  few  j&ara. 

I  take  the  liberty  of  quoting  from  Dr.  Collingworth'a 
able  address  on  "Puerperal  Fever  a  Preventable  Diaeaae."* 

"  Until  the  year  1S77  this  boRpitnl  wns  scarcely  ever 
free  from  puerperal  fev^r,  and  the  mortality,  always  high, 
occasionally  became  fearful.  In  1838,  of  71  women  deli- 
vered Ifl  died  ;  in  18(Jl,  14  died  out  of  195  ;  and  in  1877, 
9  opt  of  63.  On  several  occasious  the  hospital  had  to  be 
*  L«i»lcn :  |inl1isli«d  bf  J.  ud  A.  ChurcbUt.  1668. 


S48  rarSB   W    OfflliDBBD. 

closed  for  long  periods,  and  thousands  of  pounds  were 
spent  on  tliQ  sanitary  improTement  of  the  building.  In 
October,  1879,  this  institution,  taving  been  closed  for  two 
years,  waa  reopened,  and  has  since  been  conducted  on 
antiEeptic  principlea,  the  details  varjing  from  time  to  time 
113  increased  knowledge  and  experience  have  dictated. 
Mark  the  result.  The  total  mortality,  which  from  1633  to 
1860  averaged  30-8  per  1000,  and  ft-om  1861  to  1877  17 
per  1000.  has  fallen  during  the  last  eight  years  to  an 
average  of  6  per  1000." 


?<alai.           ' 

DeUvuiM. 

DuUu. 

ATcragc  deatb-Rte  from  ill  tonlrm. 

18S3  to  iseo 

1861  to  1S7J     1 
1880  to  18&7 

£833 
87M 

1»0 

16 

1  in    324  =  3-085  % . 
1  in    68S  =  1-696  % . 
liiil6U-0-Sl8%. 

This  table  shows  the  progressive  decrease  in  the  death- 
rate. 

During  the  last  two  years  this  average  has  been  still 
further  reduced. 

That  improvement  is  still  going  on  is  evidenced  not  only 
by  the  diminishing  death-rate  (see  Table  11)  hut  also  by 
the  steady  diminntion  of  febrile  illness,  and  especially  of 
septic  illness,  to  which  I  have  already  called  attention. 

It  is  a  source  of  gratification  to  find  that  though  the 
General  Lying-in  Heapital  has  not  yet  attained  nbsoloto 
perfection,  suchcloseapproximation  to  immunity  from  illness 
is  scarcely  surpassed  by  any  of  its  richly  endowed  Con- 
tinental or  American  contemporaries. 

Now,  on  account  of  the  progressive  character  of  the 
decline  in  the  death-rate,  which,  it  may  be  observed,  was 
initiated  before  the  era  of  antiseptics,  it  may  he  objected 
that  the  improvement  in  this  respect,  and  also  as  regards 
the  decrease  of  febrile  illness  which  has  since  taken  place, 
has  reaolted  not  from  choDgcii  which  have  been  purposely 


FEVKE    IN    CHILDBED.  243 

introdaced  into  the  service  of  the  hospital,  snch  as  I  am 
abont  to  relate  in  the  following  sections,  but  have  been 
wrought  by  the  agency  of  natural  causes.  I  shall,  how- 
ever, when  discussing  the  effect  of  atnaospheric  changes 
on  fever  in  childbed  in  the  concluding  section  of  Fart  II 
of  this  paper,  produce  evidence  indicating  to  what  extent 
natural  causes  have  afEected  the  condition  of  the  hospital 
as  compared  with  the  general  run  of  practice.  I  shall 
Bhow  how  these  influences,  at  one  time  operative  within 
the  hospital,  have  for  some  years  ceased  to  be  so.  This 
objection  will  then  be  disposed  of  completely. 


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252 


rSVIK    IN    CBILDBBD. 


BecDrd  of  Fatal  Gases. 

Tbo  nnmbcTs  i,  ii,  ill,  ftc.j  rcter  to  the  du;  of  the  paerpcrium  («■»  note, 

p.  244). 

X.  Hosp.  Rep.  2»7.  Admitted  I9th  NoTomber,  1882. 
Died  3r(J  December,  1 882.  Partial  placenta  prrovia,  "t-para. 
Early  rupture  of  membrauea  and  artilieial  dilatatiou  o( 
cervix  under  chloroform.  Hsemurrhage,  which  had  not 
been  seyere,  then  ceased.  Temp,  rose  to  103*4°  before 
labour  was  ccimpleteil,  but  aftervrarde  fell  to  normal. 

Temp,  began  to  ria©  again  on  i,  and  reached  103°  on  Ui, 
increasing  steadily  to  106-2''  on  xiii,  with  occasional  remis- 
sions of  two  or  three  degrees,  followed  by  rigors  on  viiij 
ir,  and  xii. — No  regular  after-pains.  Acute  pains  in  left 
iliac  region  on  evening  of  i,  ahdomen  distended  from  ii, 
diarrhtBHi  set  in  on  iv  and  retching  vii.  Localised  inflam- 
matory cutaneous  areas  appeared  in  various  parts  of  upper 
limba  and  on  battocke  and  forehead  after  is..  Slight 
delirivun  supervened  xii,  and  death  took  place  xiii.  Lochia 
offensive  from  iii,  continiiod  red  but  scantyj  and  occasion- 
ally stopped  for  twonty-foup  hoars  after  vi  till  death. 
Fundua  dcL-ltued  loss  readily  than  ueual,  being  stilt  four 
inohea  above  pnbes  on  vii.  Deposit  recoguiaed  in  pelvis 
by  vaginal  examination  on  ix.  Milk  came  iu  on  iii,  never 
plentiful,  but  aalhuiuat  till  ix,  when  it  failed. — Intra-uterine 
carbolic  doDohes.  Poultices  with  laudanum  to  abdomen. 
Quinine  internally. 

PoBt-mortevx. — Old  and  recent  pleurisy.  Pelvic  peri- 
tonitis. Except  for  adhesionS]  ovai'ios  and  tubes  normal. 
Thrombosis  of  right  ovarian  vein  extending  to  broad  liga- 
ment and  forming  a  solid  swelling,  Bizu  of  a  walmit.  Pus 
in  uterine  sinuaes. 

8.  Hosp.  Kep.  324.  Admitted  30th  December,  1882. 
Died  8th  January,  1883.  Cyet  (?  dermoid)  size  of  fcetal 
head,  adhereut  in  pelvis,  twice  aspirated  through  vagina. 
Temp,  rose  to  101°  afterwards.  Craniotomy.  Lacerations  of 
perinaeum  and  vagina.  l-piLra, 


PETER    IN    CHILDBBD. 


253 


Temp,  hftgan  to  rise  i,  aiifl  rfeacliod  104*  on  ii,  dropped  1* 
on  iv,  but  persisted  till  patient  bocarae  unconscious  vii. — 
Collapso  followed  labour.  Severe  bearing--down  pain  i. 
Marked  njdemn  of  labia  and  vagina,  and  uterua  very  tcndpr 
ii.  Offensive  lochia  from  iii,  free  and  red  till  after  V.  Viigina 
and  perineeam  sloaghing  iv.  Abdominal  distonsion  and 
teadopnpss,  piiin  severe  und  incren.Binf|r,  and  togs  drnwn  up. 
Patient  Rfl.nk  into  an  iinconsciocB  Btate  vii,  mid  died  ix. — 
UterineandvnginnldoncTies  of  carbolic  nnd  Condy.  Cathe- 
terisin  under  chlornform,  bUdder  imgated  with  carbolic  and 
Cond/.  Morphine  bypodermically.  Poultices  with  laudRnnm 
to  abdomen. 

Post-mortem. — Thin  pandent  Huid  in  abdomen.  Slight 
general  peritonitis.  No  cHCiipo  of  cyst  contents  into  peri- 
toneal cavity.  Sloogliiiig  grocniali  cavity  round  upper 
part  of  vagina,  involvingall  eoats  of  blsiddyp,anJ  inuPBthru- 
viigiual  septum.  Slouglis  on  wall  u£  cervix,  but  nut  of 
body.  Old  tidliesions  uf  plearre.  Venn  cava  and  iliac 
veins  hcallhy.  Left  uvary  pale,  right  injected,  both  codcnin- 
tons  and  fioftcmed.     TubcH  not  mentioned. 

3.  Hasp.  Rep.  12(i.  Admitted  5th  May,  lfl83.  Died 
26lb  May,  1883.  Normal  and  ~  easy  labour,  l-para.  No 
laceration  noted. 

Temp,  began  to  riso  ii,  and  reached  104°  on  iii,  varying 
from  103"  to  105'*'  with  considorablo  romiaaionfi  and  occa- 
aiooal  intermissions  till  death. — No  after-pains,  (ieneral 
tenderness  over  uterus  and  lochia  offensive  iii.  Maniacal 
deliritiTn  vii.  Lochia,  which  had  changed  from  free  red  to 
scanty  pink  iv,  and  from  latter  to  yellow  vii,  became  free 
white  and  again  otfenaive  viii,  and  ceased  ix.  Uinrrhcen 
net  in  xiii,  acute  pharyngitis  xriii,  vomiting  .\x,  nnd  pnca- 
monia  xxi.  Died  xxii.  Kuadiis  hud  declined  below  brim 
of  pelvis  by  xii. — BiKmuth,  ([uiuinu. 

No  poat-mortem  could  be  obtained. 

4.  Hosp.  Itep.  132.  Admitted  lOth  May,  1883.  Died 
2nd  June,  1883.  Tedious  lirHt  i^tagu,  but  otherwise  normal 
labour.    Lacerated  perinwum.     l*para. 

roc.  xxxu.  IB 


2d4 


FSVEB    IK    CEtLOBKD. 


Temp,  rose  euddpnly  iv  to  104°,  Tiu-ied  from  104*  to  106^ 
with  lunrked  reniissions  till  xii,  and  1*  lower  >vitli  slighter 
reraissiona  till  xxi,  declining  gradually  during  last  three 
days  of  life. — No  after-pains.  Offensive  lochift  from  iv. 
Shivering  fit  iv  and  rtgor  vi.  Cardiac  systolic  mumiur  at 
apex  from  vi.  Signs  of  pneumonia  from  :s.  Diarrh(c& 
from  XV.  Strabismus.  Heart  murmur  increased  much  in 
intenaity  xxi,  pain  in  knees  and  elbow  on  moveuient,  urine 
passed  involuntarily.  Slight  delirium  snpei'veiied,  aud 
death  took  place  xsiv.  Fundus  declined  below  pelvic 
brim  vii.  Lochia  changed  from  free  red  to  scanty  piuk  iv, 
and  ceaaed  viii,  hut  purulent  discharge  x — xiv.  Vaginal 
csaniiuation,  is,  revealed  nothing  abnormal  in  pelvis.  Peri- 
nooal  wound  healthy.  No  abdominal  distension  or  tender- 
DC83.  Appetite  good  throughout,  asking,  ivii,  for  beer  and 
ranttoD  chop,  and  to  be  allowed  to  sit  up, — lutm-utorino 
douches  of  carbolic  vi,  vii,  and  viii.  HiEnuith  and  mor- 
phine.    Ice  cap  and  Sod.  Salicylat. 

PoH-moTiem. — No  general  or  local  peritonitis.  Eccliy. 
moses  oa  visceral  pericardium  Jind  on  vistenil  pleurn. 
Vegc-tationa  on  mitral  and  tricuspid  valves,  to  which  adhere 
decolourised  clots,  but  it  ii^  uncertain  whether  nlcenitcd  or 
not.  Hypostatic  pneumonia.  No  pu^  aaywhcre.  Uterus 
hofilthy.  Ovaries  healthy.  Tubes  not  mentioned.  Left 
pampiniform  pluxua  blocked,  clot  commencing  ono  inch 
from  uterus.  The  clot  is  old,  partly  decolourised,  firm,  adhe- 
rent, and  sweet.  Large  yellowish  infarct  in  right  kidney 
(estimated  a  fortnight  old). 


6.  Hosp.  Kep.  330.  Admitted  23rd  December,  1883. 
Died  8th  January,  1884.  Tedious  first  atngCj  but  otherwise 
normal  and  enwy  Jnbonr.  Syphilitic  fiubjeet.  No  laceration 
found,      l-para. 

Temp,  rose  suddenly  iii  to  103-4%  varied  between  that 
point  and  104(i'^  till  is,  whftn  it  fell,  and  became  sub- 
normal xi — xiv,  with  occasional  rises  to  102°. — Very  little 
after-pain  ii.  Shivered  iii,  and  again  iv.  Signs  of  bron- 
chitie  appeared  ili,  abdominal  distension  and  tenderness  iv, 


FXVEB    IN    CHILUBED. 


266 


lEToluntary  micturition  with  offensive  lochia  and  urine  vii 
and  viii.  Slight  deliriniu  ix.  Persistent  diarrhcea  eet  in 
and  vomiting  xii.  Patient  became  unconscioas  xvi,  and 
died  xvii.  Fundus  quickly  declined.  Hreaence  of  exuda- 
tion in  pelvis  ascertained  by  vuginal  examjuation  xi.  Lochia 
fren  red  (or  first  five  days,  scanty  yellow  and  occasionally 
blood-atained  till  cessation  xii. — Fomentatioasto  abdomen. 
,Icacap.  Sod.  Salicylat.  Cathoturism.  Bismutti,  inarpliine, 
and  hydrijcj'unic  acid. 

Poai'Viartem. — Old  pleuritic  ftdbusionis.  Hypostatic  con- 
gestion and  bronchitis.  Fibroid  induration  of  heart  and 
heart  valves,  spleen,  and  kidnoys,  whicb,  in  addition,  nto 
lar^fe  and  palo.  Poritoneuiu,  except  in  pelvis,  healthy. 
Recent  adhesions  of  uterus  in  Douglas's  pouch.  Ovariex 
pale  and  large,  but  otherwise  healthy.  Uterus  well  in- 
voluted, and  presents  nothing  abnormal  on  internal  aspect. 
Tnbcs  healthy.  At  upper  part  of  anterior  vagiual  wnll 
are  two  holes  with  clean-cut  edges,  each  the  ai?,e  of  a.  aix- 
ponce,  one  on  cither  side  of  tbe  middle  line,  with  a  ttimilar 
bat  smaller  hole,  not  larger  ihaii  a  lentil,  below  and 
between  them.  They  i « tore oinmnni cat e,  and  lead  to  a 
cavity  rather  larger  than  a  crown  piece.  The  wall  of  this 
cavity  18  iaSltrated  with  reddislL-yeliow  material,  and  in 
two  spots,  which  are  adjacent  to  softened  and  infiltrated 
parts  of  the  mucous  membrane  of  the  bladder,  in  in  a 
xlanghiag  condition.  An  extension  of  this  cavity  runs 
towards  the  base  of  the  broad  ligaments  on  either  side,  and 
on  the  right  reaches  very  close  to  the  inflummatory  focns 
there  situated.  Tlie  left  broad  ligament  prettents  no  such 
infiltration,  but  that  on  the  right  cstondB  upwards  into  the 
iliac  fossa  of  the  name  side,  where  it  follows  the  course  of 
the  ureter  to  the  kidney,  and  extends  forwards  along  the 
round  ligament  as  far  ae  the  internal  abdominiil  ring. 
itcftdsof  puti  having  a  chain-like  arrangement  are  collected 
in  either  broad  ligament  in  the  space  bounded  by  the 
Fallopian  lube  above,  and  the  ovary  aad  its  ligament 
below.  On  the  posterior  wall  of  the  uterus  beneath  it^ 
peritoneal  coat  are  xeveral  tiiiinll  purulent  collections,  gener- 


266 


PXTEIt    IN    OniLDDBn. 


ally  not  larger  thnn  a  pea,  but  one  is  as  large  as  an  altnond. 
Many  of  tieae  collections  are  almost  solid  iu  consistence. 

6.  Hosp.  Rep.  38.    Admitted  23r(i  Pebi-uavy,  18»+.     Diedj 
27t-h  March,  IriS-t.  Tedious  labour  witli  gLMierally  cont«MJt«€ 
pelvta,    1-para.  Inertia  and  post-partnni  liieinorrliage  to  the 
extent  of  HO  07..     Pourctette  lacerated,  but  no  deep  tear. 

Temp,  began  to  viae  ii,  and  reached  103'2°  on  iii.  From 
ttis  point  it  gradually  declined  with  slight  remiBsions  to 
101*'  on  viii,  but  on  is  again  roso  to  103'4*  eontinuing 
betwoou  102'^  and  105°  nntil  death  occurred. — No  after- 
pains.  No  abdoiuiual  dt.stensioD  or  teuderuess,  the  patient 
sleeping  and  eating  well  to  within  a  few  days  of  death. 
Slight  frontal  headache  on  x,  replaced  by  occosior 
delirium,  elight  from  xii  to  ixxiii,  after  which  it  bocainc 
a  prominent  feature.  Slight  pain  and  ewelliug  in  right 
shoulder  from  xii  and  in  right  hip  on  xxix.  Slight 
bronchitis  from  xii.  Loc^hia  not  offeuBive,  free  and  rod  for 
first  four  days,  yellow  after,  ceaaed  xvi.  Laceration  hoaled. 
Fundus  declined  naturally  and  reached  brim  vi.  Cervix 
by  vaginal  examination  on  xsviii  found  to  be  fixed,  but  no 
deposit  of  appreciable  thickaese  could  be  felt.  Milk  canie 
in  slowly  on  iv  and  v,  plentiful  on  ri,  hut  disappeared 
gradually  after  xv.  Strength  began  to  fail  from  that  date, 
and  deathtcokplneoon  xxxiv. — Sod.  Salioj'Int.,  qmnine,  and 
digitalis.     Stimulants. 

Post-mitrtein. — Mitral  valveK  slightly  and  one  of  tricuspid 
valve  flaps  much  thickened.  Edematous  lungt;.  Tiivcr,, 
spleen,  and  kidneys  present  nothing  beyond  ordinary  signal 
of  fever.  Pelvic  organs,  with  the  exception  of  prolapse  of 
left  ovary  into  Douglas's  pouch,  bok  healthy  from  abdomen, 
bnt  on  cutting  into  uterus  pus  e-xudes  from  sinuses  over 
situatiou  of  placental  site  (left  posterior  part).  Adjacent 
uterine  voina  contain  adherent  clots,  and  also  both  iliac 
veins.  Similar  clots  are  foQnd  in  vona  cava  as  high  as  first 
lumbar  vertebra,  and  in  femoral  veins  as  low  am  middle  of 
thigh.  Uterus  appears  \'eiy  well  involuted.  No  mention 
of  tubes.     Cervix  and  vagina  normal. 


VKVER    Ih'   unimDBj). 


257 


7.  Hosp.  Rep.  03.  Admitted  ind  March,  1885.  Died 
11th  March,  1885.  AdvauceJ  phthisis,  very  ill  on  admis- 
aiou.  Sovere  cough  fi>r  sis  months  previously  and  hmmo- 
ptysis.     Normul  labour,  -t-para. 

Temp,  iinmutliat.ely  after  labour  1(K)4-'^,  hut  snme  oven- 
iuy  rose  to  103*4",  and  jmrsistpd  with  variable  remis- 
sions at  103* — 104°  till  death. — Little  milk  appeared  in 
breast  iii.  Diarrhcoa  set  iu  iv.  Distressiug  cough  and 
dyspucea  persiated,  patient  bocainy  gradually  weaker  and 
died  ix.  No  abdominal  paia  or  tundemBSs.  Lochia  uot 
oEfensive,  scant;y  pink  tliruughout  except  vi  aud  vii,  when 
thuy  WLToydlow.  Fundus  steadily  declined,  uxteiidiug  foui- 
inuhes  above  pnbea  vi. — Morphine  linctiis.  Ipecacnaoha. 
Ui»Diuth.     Stimulants. 

No  pubt-mortem  could  bo  obtained. 

8.  HoBp.  Rep.  106.  Admitted  1 4th  Api-il,  1885.  Died 
22nd  April,  1885.  Advaiictjd  phtliiai»f,  vuM-y  ill,  with  temp. 
lOl"^^  un  adinissioii.     Normal  labour,  8-para. 

Temp,  fell  below  100°  after  labour,  hub  rose  same 
evening,  peraisting  at  102°— 104°  with  slight  remissions 
till  death. — Little  milk  appeared  in  broasta  ii.  Weakness 
increased,  dyspucea  at  timea  becaiuo  excessive,  and  death 
occarred  vi.  Lochia  free  red  for  firsttwo  days,  scanty  pink 
aftci" ;  not  offon.iive.  No  abdutninal  pain  or  tendeniesH. 
yundu.i  extended  but  three  inches  above  pubes  ii. — Ips- 
cacuanha.     Stimiilauts. 

Post-viortem. — Hoth  lungs  riddled  with  cavities,  adherent. 
Tubercular  and  purulent  glands  in  inediostina.  Liver 
adherent.  Kidneys  large  and  pale.  Pelvic  orgunn  healthy, 
2  oz.  clot  adherent  to  placeatal  sito  and  2 — 3  os.  Iluid 
blood  iu  uterine  cavity. 

9.  Hoap.Rep.  244.  Admitted  •22nd  Angunt,  1885.  Died 
7th  Kopt^iuibor,  18t;5.  Mercurialisui  and  uiorphUin.  Already 
luportcd.  Soo  Dr.  Dahin's  paper  on  "  Mercurialigm "  in 
'Obat.  Trans.,'  vol.  xxvjii,  1886,  p.  200. 

10.  Hosp.  Rep.  20S.    Admitted  1  st  Octobur,  1885.     Died 


258 


PBVEB    IH    oaiLBSRP. 


19th  October,  1885.  Post-pni-tum  brotnorrh age  to  tho  extent 
of  50  oz. ;  othcrwigQ  normal  labour.  Ko  lacemtion  noted. 
I -para. 

Temp,  began  to  rise  it,  and  reaclied  101°.  Sligbt 
sliiveriug  fit  oii  vi,  and  mgain  on  viii,  when  102'8®  was 
reached.  Next  day  with  severe  rigor  teroperatiire  rose  to 
105'8*,  and  from  this  point  was  very  irregular,  marked  re- 
miHsioQB  and  intermiitgiona,  followed  by  repeated  eliivermg 
fits  aud  rigors,  oceurred  during  the  next  three  days,  bat  on 
the  whole  the  fever  declined,  and  temp.  appu.reDtly 
normal  during  the  last  few  days  of  life. — No  after-pains 
and  no  distension  of  the  abdomen  nor  pelvic  pain  till  xi, 
then  alight  and  soon  passed  oS,  bnt  returned  xiii.  Bpi- 
gsftric  pain  is,  also  alight  aiid  evanescent,  but  returned 
with  hiccough  ivii.  Feeble,  irregular,  and  intcruiittent 
palse^  and  occasional  cardiac  bruit  from  x,  more  distinct 
subsetiuently.  Persistent  vomiting  and  purging  from  xii. 
Contiuned  hitherto  to  tnke  nourishment  well,  but  stivngtli 
now  began  to  fail  rapidly.  Passed  dejecta  uncoascioaaly 
from  XV,  gradually  sank  and  died  sviii.  Lochia  variable  in 
amount;  red  or  pink  till  x ;  stopped  xi ;  yelloWj  scanty  xii; 
oeaeed  permanently  xiii  j  ofiensive  vii  and  viii.  Fnndus  de- 
clined slowly,  remained  highertban  usual,  being  four  and  a 
half  inches  above  pubes,  viii.  Nothing  abnormal  found  by 
vaginal  exnminatioa  xii.  Milk  came  in  iv,  bnt  not  freely. 
Nipples  soru  vi,  afterwards  milk  luoro  plentiful,  but  almost 
disappeared  ix. — Wet  pack,  bismuth,  stimulaiits. 

Post-mortem. — No  peritonitis.  Riglit  ovarian  vein  divides 
and  enters  vena  cava  inferior  by  two  openings  au  inch 
apart,  both  of  which  are  plugged  with  soft,  highly  organ- 
ised, adherent  clot,  breaking  down  iu  ike  centre.  The 
ovarian  vein  is  blocked  by  chocolate -col  on  rod,  eetai-Boid 
clot,  which  extends  downwards  to  the  ovarian  plexus  of  the 
samo  side,  but  ends  abruptly  opposite  the  inner  border  of 
the  ovary,  and  on  carefully  slitting  up  the  uturine  ninuHeR 
nothing  abnormal  discovered.  Abscess  in  right  suprarenal 
body  the  size  of  a  walnut ;  the  plexus  of  Teln»  lying  between 
this  and  ovarian  veiu  is  composed  of  bhick-walled  veaaels. 


FBTSB    m    CHILDBBD. 


259 


which aremattedtogctli&r  and  tilled  with  somi-fliiid  grumccufl 
inatmnR.1.  All  other  veins  healthy.  No  plugging  ou  oppo- 
site side.  Ovaries  and  tubes  normal.  Haimurrhagic'  spols, 
infarcts,  and  minute  abscesses  iu  kidneys,  aplocn,  and  liiugu. 
PftL'chia;  under  serous  covering  of  lungs,  heart,  liver,  and 
iutuatine,  beneatli  endocardinui,  and  beucatli  mucous  mem* 
brtiuQ  of  stomach  and  inteBtine. 


11.  Hoap.  Rep.  848.  Admitted  2tJth  Novotnber,  1888. 
Died  1st  December,  l88ti,  Eolauipsiu  supervened  during 
iirst  stage  of  labour  (two  file  of  epileptiform  chiiraeter). 
Forceps  delivery  under  chloroform.  Stillbirth.  Manual 
removal  of  placenta.     Perimcal  laceration.     1-para. 

Temp.  lOO-i**  i,  roee  to  104°  ii,  but  declined  to  normal  lii. 
Began  to  i-ise  again  during  last  tweuby-foar  hours,  and 
reached  105*  juet  before  death. — Fite  continued  after  de- 
livery, two  i,  and  no  less  than  twelve  ii.  Patient  then  sank 
into  Bemi-comatusecoDditiuu,  from  which  she  never  rallied. 
•Tanndice  and  vomiting  set  in,  and  herpes  labiaJis  appeared  v. 
Death  vi.  Lochia  changed  from  fi-ee  red  to  .scanty  brown 
V,  not  offensive.  Fundns  declined  to  three  and  a  half  inches 
above  pubcs  \n,  and  there  remained  ;  laceration  healed.  No 
milk  appeared.  Urine  drawn  during  labour  deposited  one- 
fourth  albumen  with  lieat  and  nitric  acid,  aud  was  found  to 
contain  many  fatty  and  grnnular,  and  few  hlnod  and  hyolino 
casts.  Albumen  decreased  to  a  trace  iii,  but  afterwards 
increased. — Croton  oil  by  mouth,  bromide  and  chloral  ono- 
mata.     Chloroform  inhalations.     Dry  cupping.     Ice  cap. 

Past-^wrtem, — Pelvic  organs  healthy,  Ualf  ounce  dark 
fluid  blood  in  uterine  cAvltj.  Pelvic  veins  normal.  General 
deep  ictcriu  tint.  Gall-ducts  healthy.  Liver  substuncu 
pale,  soft,  and  friable,  granular  on  section  ;  capsuli;  rather 
adherent.  Kidney  eubstaEOc  very  toagh,  and  capsule  ad- 
lierentj  palo  on.  section.  Brain  more  vascular  than  normal, 
with  many  fine  extravasations  on  and  between  convobitions. 
Subpleural  petechiw.     Heart,  spleen,  and  lungs  normal. 


12.  Hosp.    Kep.   828.      Admitted   mii   October,   1887. 


SflO 


KKVICK     IN     CBI1.DUIC1). 


Diet!  31hI  Octuber,  1887.     Normal  l»1>oui-.    Slight  labit 
teai'.     1-para. 

Tomp.  ran  up  from  nomml  to  1(>6'2°  in  first  tweuty-four 
hcui-B,  then  deeliuGd  to  normal,  Ijut  agaia  rose,  and  reaoliod 
104.°  at  de».th. — Severe  headache  complained  of  swou  after 
delivery.  KctHtnpsia  supervened  tweut/-foar  houra  after 
labour;  ten  fits  of  upileptiform  character  followed  ono 
another  iu  quick  succcskiqu.  Patient  sank  into  tscmi-coum- 
tosu  statu,  uud  died  thirty -six  koure  after  deliTcry.  Lochia 
free  red  i,  scanty  ii,  uot  ofEcubive.  Urine  on  eact  occasion 
dmwn  by  catlietoi'  found  to  contain  one-sixteenth  itlbumen 
by  boat  mid  mtrio  ncid. —  Clilorofonn  inhalations.  IJromido 
and  chloral  pur  re-ctum.  Pilocarpiuo  EypodermicaUjT.  Dry 
cupping.     Vapour-bathB. 

Poet-triorkm. — Pelvic  organs  normal  oxceptovaries,  which 
arc  very  cedeuiatouu  and  cuntuiii  numiLTouB  small  cyBts  up 
to  Hizo  of  a  pea.  Heart  uud  lungs  healthy.  Kiducy 
pyramids  normal,  bnt  cortical  substance  diniinisLed  in  quan- 
tity a.ud  light  in  colour.  Liver  light  in  colour,  uud  some- 
what nutmeg  iu  appearaMCo  on  seetiou.  Brain  uot  txaniiuod. 


13,  Uosp.  Rep.  334.  Admitted  2nd  September,  1888. 
Died  ^3rd  SeptL*mbcr,  1888.  Contracted  pelvis.  Unsuc- 
ceBsTuI  utteniptB  to  deliver  with  forceps  made,  aud  vogii 
and  cervix  lacurutud  bufori;  iidmisKion.  Subaequeut  appli- 
cation of  forccpa  iindcr  chloroform  unsuccessful.  Ccpbalo- 
tripsy.    Lacerated  perinteum  nusutured.     2-paro. 

Temp,  begun  to  riHc  gradually  from  iii,  and  reached 
102'4°  is,  and,  with  exception  of  transitoi-y  i-ise  to  104"2'^ 
xiv,  reuiaiued  102° — 103"  till  death. — Extreme  exhaustion 
followed  labonr.  Vomiting  occurred  iii,  and  rectal  alimen- 
tation resorted  to.  Periuieuni  sloughing  iv,  vagina  vii, 
iodoform  bougie  inserted  j  urine  offensive,  boric  acid  irri* 
gation  of  bladder.  Lochia  chnngcd  from  free  red  to  pink 
on  vi,  inid  to  yellow  on  x  ;  offensive  from  iv  onwards.  I're* 
queut  douches  of  iodine  used  from  vi.  General  condition 
improved  during  first  fortnight.  Appears  to  have  had  a 
fit  xiv^  and  developed  acute  maiiiii,  nece:>eit&titig  return  to 


rSTBIt    IK    CBILDBBD. 

notel  alimentation  and  use  of  cutioplingoal  tube.  Bnddenly 
became  rational  svi.  Weakaoss  increased.  Uolirium  xxi. 
Diod  xxii. — Stiumlauta. 

ronl-murte7n. — Sloughs  vi  puriua'uiii,  vagina,  aud  i-crvix. 
Budy  of  atcras  liealtliy.  Tubes  nut  iiit-utiiunod.  Ovu-ries 
nuiinal.  Abscess  beneath  right  iliacus  couuectud  with 
sluugh  on  vaginal  wjvll,  situiiiud  oni;  inch  beiaw  cervix  i>u 
right  Bido.  B;>lh  broud  ligunieuttt  Lontaiii  uattcouttdepufiitH, 
iLud  the  cc-Ilular  tissue  is  hard  aud  dense.  No  indicfttiuu  o£ 
peritonitis. 

14.  Hosp.  Rep.  581.  Admitted  4th  October,  1888.  Di«d 
I2lh  October,  1888.  Normal  la-bofti".  Slight  puriiiaiul  tuur. 
I'piiru. 

Teinp.  began  to  rise  iii,  and  reached  101°,  ran  up  to 
104"4°  V,  but  fell  iiumediately.  Kosc  from  normal  tu  1U4*4° 
again  viii,  but  declined  inimediateEy,  and  ran  up  tigniu  to 
103°  jntit  before  death. — Un.ia.sts  beciimu  distended  iii,  bnt 
patient  seemed  going  on  well  till  v,  when  perina'n.1  tear 
looked  unhealthy;  headache.  Lochia  changed  from  froe  red 
to  scanty  pink  vii,  offensive  from  yii.  Rigor  Tiii,  alight 
abduMtiual  pain  and  tenderness.  Patches  uf  phlogmuuuut) 
cellulitis  appeared  on  left  shoulder  and  buttuck  is,  inid 
spread  rapidly;  butt^ick  incised  freely  under  chlorofurm, 
ga«  and  iiiiniou<t  fluid  e.>}capcd  ;  oppression  iLt  chest ;  collapse 
and  death  same  day. — Quinine.  Peultioes.  Sublimatoijubiiti- 
tuted  for  aalufer  day  before  deiitb,  and  iutra-nteriiiL"  douche 
given  ix,  washing  out.  offensive  membrane  aud  clot  from 
cervix. 

Postfiiortem. —  Ilapid  putrefactive  changes  in  organs  and 
tissues.  Gangronuus  cellulitis  uf  shoulder  and  duisuni, 
buck  of  left  thigh  and  culf,  in  region  of  left  ankle-joint., 
Qud  on  sole  of  right  foot  (surmounted  by  large  bulla  con- 
taining saniourt  fluid).  Bhick  ami  sloughy  discoloration 
can  be  traced  almoi^t  coutinuonsly  from  slight  tear  of  pori- 
u&;um  to  gangrenous  focus  in  left  buttock.  Dlood-stsiiued 
iluid  in  pleural,  pericardial,  and  pentoneal  cavities.  Heart 
cavities  contain  tarry  blood.     Marked  post*mortcm  slain- 


262  rSTBB   IN  CHTLDBSD. 

ing  of  endocardinm.  Femoral  veins  and  veins  of  broad 
ligaments  filled  with  dark,  semi-fluid  blood-clot.  Some  of 
sinnses  beneath  placental  site  filled  with  yellowish-brown 
gromone  material,  nterus  otherwise  healthy.  Ovariee  and 
tubes  healthy.  No  purulent  collections.  Submucous  heemoiv 
rhages  in  bladder. 

16.  Hoap,Bep.  236.  Admitted  27th  June,  1889.  Died 
same  date.  Admitted  on  accoant  of  severe  accidental 
haemorrhage  at  seven  and  a  half  months.  Rupture  of  mem- 
branes, artificial  dilatation  of  cervix  and  podalic  version 
under  chloroform.     Stillbirth.     5-para. 

Post-partum  haemorrhage  to  extent  of  nearly  one  pint. 
Hand  introduced.  Collapse  and  death  one  and  a  half  hoars 
after  delivery. 

Post-mortem. — No  abnormality  beyond  signs  of  htemor- 
rhage. 


PBTBB   IH   CBILDBZD. 


III.  The  service  oj  tht  Hotpital  during  thin  ge^tejtnial 
jterxod ;  ijicreased'  attention  to  points  o/  yenerai 
hytfiene  ;  constant  wk  of  antiseptiat. 

(UMMTcd  I>««»il>«T  lUth,  L8S0.} 
(Abatrad.) 

A  (lescriptiLiu  of  tbu  Hi>spitul  iiiid  of  tbc  melhod  in  which  its 
wrricc  hits  been  oanductctl  is  dotailed.  Such  altemtions  oC  a 
gtovinl  hygii-^oic  uattire  as  \ta.vQ  bt-en  cfEtuteU  during  tbc  period 
under  considomtiou  are  dwutt  upon. 

Attention  is  direct«<l  to  the  fact  that  duriui;  the  wbolc  of  the 
time  the  sauie  ijriucii>1e8  bare  preniled — a^utisqiticH  hare  been 
in  tioost&nt  use,  but  ihc  details  bare  been  chan^ng.  ui)pcut«Uy 
with  tvgard  to  the  strength  luid  character  ot  the  eotutionn  «!tu> 
ployud.  Tbueuwill  be  euiisidered  in  detail  ia  the  two  suix-eeding 
aectiouH. 

Abont  four  years  ago,  through  the  instrnmentality  of 
Dp.  Priestley,  the  Fe-Uowa  of  tbiu  Society  were  made  con- 
venmnt  with  the  maoagement  of  some  of  the  lying-in 
liuspitals  in  the  north  of  Europe.  3  feel,  therefore, 
encourag-ed  to  place  on  record  a  short  description  of  the 
Bcrvice  of  the  hospital  which  has  provided  material  for  the 
present  paper,  Siich  description  will  serve  as  a  fitting 
prelude  to  the  changes  which  have  been  effected  iu  tho 
aervicc  duriug  the  period  now  under  consideration. 

Situ  anc  .Steucture. — As  regards  the  General  Lying-in 
Hospital  no  structural  alterations  have  taken  place  dnring 
tho  aoptonnial  period  above  referrod  to,  nor  indeed  for 
some  years  before  that.  Founded  in  1765,  the  hospital 
occupies  a  position  on  the  south  side  of  the  Thames,  in 
the  densely  populated  part  fif  Laniheth  m-iginally  and  not 
inaptly  called  "  The  Marsh."  The  present  biiitdiog, 
erected  sixty  years  ago,  may  bo  said  to  cojnpriBO  eight 
wardii  fur  tho  aocomuiodutiou  of  lying-in  patients,  distrU 


FKVRR    IN    CHILDBED. 


2ft5 


buted  on  tlie  ground  aod  first  floors.  Moat  of  the  Ij-ing-in 
wards  contain  three  beds  apiece  ;  one  rather  larger  than 
tlie  rest  liaa  fonr,  tlie  cnnvalescent  ward  four,  the  isolation 
one — giving  a  total  of  twentj-four  beds.  A  clear  cubic 
space  of  200l>  feet  ta  allowed  for  each  bed.  Encli  floor  is 
provided  with  a>  labniir  ward  for  the  reception  of  one,  or, 
if  occasion  require,  of  two  pntJents. 

The  Willis  and  ceilings  of  all  the  wards  arc  painted. 
An  uttcHipt  has  boon  made  to  polish  tlio  floors,  but,  except 
in  ono  of  the  labour  wards  (which  was  laid  afresh  nith 
teak  four  years  ago),  was  nbandonod  in  conscqueiioo  of  the 
unsuitable  uatare  of  the  surfaco  prosouted  by  the  old  deal 
boards. 

Braisaqk.— Cloaets  and  slop-sinks  are  provided  on  each 
floor,  built  out  in  a  turret  from  the  main  building,  and  are 
80  consti-uctcd  as  to  include  a  passage  whicdi  is  shut  off 
from  tlio  corridor  by  doora  and  ventilated  by  meauR 
of  open  windows  on  either  side.  All  the  di-aine  run  out- 
side the  building,  and  are  furnished  with  traps  for  iuspec- 
tion  and  ventilation  in  the  four-foot  area  which  surrouuda 
the  hotipital  on  the  basement  lovol.  Th'O  drains  arc  dio- 
coiinecl&d  with  the  main  by  n  diptrap,  and  iire  fhisihed 
autoraatically  every  twcdvo  hours  by  nioaus  of  a  lOO-giillnn 
trAuk  placed  in  the  tower  which  surmount»  either  vring  of 
the  building.  The  fioil-pipes  are  ventilated  by  a  continu- 
ation upwards  of  the  shaft  above  the  top  of  the  building. 

VxirriLATioN  ANii  WABiliNa. — At  very  conBiderabIc  outlay 
hot-air  pipei*  had  been  laid  oa  throughout  the  hoi^pital,  and 
each  ward  had  been  provided  with  an  outlet  veutilnting 
shaft;  but  8f>  inefficient  did  this  method  of  ventilation 
prove  that  for  the  l«st  ten  years  tlioy  linvo  been  discarded. 
A  fire,  howovor,  is  kept  constantly  burning  in  the  open 
grate,  and  all  the  windows  open  at  least  six  inches  al  top 
(the  amount  depending  on  tlie  state  of  the  weather),  and 
the  inside  Venetian  blinds  turned  so  b»  to  direct  the  in- 
coming air-current  upwards.  In  one  ward,  in  which  all 
the  windows  are  on  the  same  aide,  Tobin's  tubes  are  also 
provided.     Inlet  veotilatora  are  also  placed  near  the  floor 


2«0 


FEVER    tM    CHILDBED. 


and  Sherriagliam  valves  at  tlio  cpper  part  of  the  ootor 
wall  in  all  the  wards. 

CLOfHitfOAND  Bedding. — Kach  lying-inward  and  delivery 
room  is  provided  with  its  own  set  of  iustrumenta  and 
nteuBtla.  Hnir  mattresses  are  employed.  The  requisite 
supply  of  bedding  and  clothing  ia  given  out  direct  from 
the  store  for  each  ward.  It  is  strictly  forbiddeu  to 
transfer  clothing  or  bedding,  or  instrutnentB^  &o,,  from 
one  ward  to  another.  Both  infants  and  mothers  are 
provided  with  special  clothing  throughout  their  8tay  in 
liospital.  A  cot  18  placed  in  each  lying-in  ward  for  the 
accommodation  of  two  children.  The  clothing  in  which 
tha  women  enter  is  removed  on  admission.  This  used  to 
be  "  staved  "  and  laid  by  in  the  hospital  until  the  patient 
iVBB  discharged,  but  isiuce  the  outbreak  of  scarlet  fever, 
now  nearly  sis  years  ago,  it  is  in  many  instances  removed 
by  the  friends  and,  together  with  a  change  of  nnderltnen, 
brought  back  when  the  patient  leaves.  The  laundry-work 
is  contracted  for  outaide  the  hoBpilal.  All  soiled  linen 
used  to  be  soaked  either  in  bay-salt  soltition,  in  order  to 
remote  the  blond-stains,  or  for  some  time  after  the  scarlet 
fever  in  1  in  40  carbolic  solution,  but  of  late  it  hati  beeu 
despatched  three  times  a  week  to  the  laundry  without  being 
previously  dealt  tvitht  When  returned,  the  clothes  are  put 
into  a  Frasev  stove,  which  uEtid  to  be  raised  to  220*  F., 
but  since  the  above-said  scarlet-fever  period  to  250*  F., 
more,  however,  with  a  view  to  airing  it  efficiently  than  of, 
effectually  destroying  infection,  Until  within  the  last 
three  years,  not  only  the  personal  clothes  and  bedding, 
but  the  niattressps  also  were  before  use  "stoved,"  with 
the  idea  of  ridding  them  of  possible  infection,  but,  as  in 
the  stove  with  which  the  hospital  is  provided  it  was  found 
impossible  to  maintain  the  heat  for  a  sufficient  time  with- 
out injury  to  the  fabric,  this  practice  was  discontinued. 
At  the  same  time  each  mattress  was  numbered,  and  a 
legistor  was  instituted  of  each  patient  for  whom  it  was 
nsed,  so  that  nny  defect  might  be  at  once  traced.  Any 
mattress  which  has  been  used  for  a  case  likely  to  infect  it 


FBVEB    IN    CHILDBEU. 


267 


is,  Tiowever,  at  ouce  sent  away  iu  order  to  undergo  disin- 
fection by  superheated  steam. 

FirMiOATlON  AND  Cleanihq. — The  labour  wards  aro  fumi- 
gated and  washed  after  every  six  deliveries.  Tlio  lyiug- 
in  vards  are  disinfected  after  the  beds  hare  heen  onco 
occupied.  When  a  ward  is  vacated  by  a  batch  of  [latientu, 
the  bed-linen  ia  remuved,  but  the  iiiattres»eg  and  hlaakets 
are  suffered  to  remain  suspended  during  the  process  of 
fumigation  and  removed  afterwards.  Five  pounds  of  sul- 
phur are  burnt;  in  the  lying-in  and  two  pounds  in  the  labour 
wards.  The  ceiling,  walls,  floor,  bedateads,  Ac,  are  then 
washed  down  with  carbolic  solufciou  I  in  20.  During  the 
last  three  years  the  famigation  has  been  performed  between 
each  batch  of  patients,  the  additional  washing  between 
crery  other  batch.  Before  that  it  was  the  practice  to  fumi- 
gate, to  wash,  and  then  to  fumigate  ngaiu,  not  between 
erory  batch,  but  between  every  other  b«teh  of  patients. 

Staff. — BeBides  the  physicians,  who  visit  twice  a  week, 
the  Htaff  consists  of  a  Louse  physician,  who  usually  remains 
in  office  for  about  six  months  and  resides  continvioagly  in 
the  lloppital  ;  a  matron,  who  manageH  the  housekeeping 
and  Buperintendg  the  niu'oing,  aud  a  head  midwife,  who 
euperrises  the  cases  in  the  labour  wards.  These  are  the 
only  permaaeut  memherB  of  the  resident  staff.  But  tho 
hospital  posscescs  a  flourishing  training  school,  both  for 
midwives  and  mirses.  Tho  former  nre  received  into  the 
hospital  for  a  period  of  three,  the  latter  of  two  monthB. 
No  pupils  from  outside  are  admitted,  but  there  is  a  large 
extern  department  connected  with  the  hoKpital  served  by 
separate  midwives,  who  reside  in  their  respective  districts  ; 
and,  though  the  pupil  midwives  attend  during  part  of  their 
training,  on  cases  in  the  liome  district,  they  are  lodged 
meanwhile  in  the  house  of  the  midwife  under  whose  super- 
inteudencc  their  cases  are  coudacted,  mid  are  not  permitted 
to  take  pan  during  that  time  in  practical  work  within  the 
hospital.  Whilo  on  dntj  within  the  hospital,  both  mid- 
wives  and  uiirseaaro  required  to  droiju  in  washing  material. 
Separate  day  nurdee  arc  provided  fur  eB,ob  ward,  otid  a 


2Q8 


7KTRII    IN    CHILDBED. 


Separate  niffht  nurse  for  each  floor.      The  nurses  nSRist  nt 
tlio  labour  cases  in  rotatiuu. 

Admission  op  Patients. — Patients  are  admitted  by  letter. 
The  only  applicants  considered  unsuitable  are  those 
affected  vritli  foul  wounde,  which  wonld  entail  risk  to  other 
putionts.  Single  women  in  tlie  first  confiDemeiit  hre  ad- 
mitted ott  special  conditioDS. 

Conduct  op  Laroub. — Patients  are  more  or  less  advanced 
in  InbouT  on  admission,  and  nre  condnctod  at  once  to  tho 
labour  ward.  They  aro  iinmediately  dressed  in  hospital 
clothes,  and  in  all  cases  whero  tima  will  allow  the  passages 
are  irrigated  with  throe  quarts  of  antiseptic  solution  before 
delivery,  the  doucho  being  repeated  it  the  labour  bu  pro- 
Icugcd.  One  or  more  such  vaginal  douches  at  a  tcmporn,- 
tnre  of  115°  F.  aro  invariably  given  after  labour  ia  com- 
plete,  and  any  considerable  tears  about  the  vulva  are  imme- 
diately closed  by  suture. 

CosDoCT  OF  Lying- ly. — Two  hours  later  the  patient  is 
rpmnved  on  a  trolley  from  tho  doliverj'-rooni  to  the  lying- 
in  ward.  Patients  are  restriotcd  to  a  slop  diet  Lniil  the 
bowt'la  have  been  freely  rolievod,  but  generally  on  the 
third  day  fish  and  afterw.irds  meat  is  given.  A  liberal 
supply  of  milk  is  allowed,  but  no  stimulants  unless  speci- 
ally ordered.  Prior  to  1884,  however,  it  vraa  tho  rnle  to 
Pfive  beer  with  dinner  after  the  fifth  day.  It  was  discon- 
titnietl  on  the  ground  that  the  patients  were  frequently  ren- 
(Icrod  uncomfortable  and  feverish  for  a  few  hours  after  it 
had  been  partaken  of,  and  suhsequout  exporioncehaa  tended 
to  confirm  this  when  it  has  been  given  in  individual  casoa. 
After  the  fifth  day,  the  patient's  friends  are  permitted  to 
vifiit  on  two  aftemoous  in  the  week.  As  a  rule,  patients 
are  allowed  up  in  a  tcmlative  way  on  the  ninth  day,  and 
all  are  carefully  examined  by  the  visiting  physician  pre- 
vious to  departure. 

Antiskh'ic  Mkasokes, — The  vaginal  douche  at  a  tempe- 
rature of  110°  F.  19  employed  as  a  rontine  measure  nigbt 
and  morniug  until  the  lochia  have  ceased.  From  three 
pints  to  two  quarts  of  the  solution  are  used  on  o&ch  occa- 


FEVEK    rit    CHILDBED. 


269 


sion.  PnJs  of  absoiTiont  cotton  and  onltom  and  latterly 
of  sublimHted  wood-wool  are  osed  instead  of  diapers,  aud 
when  removed  are  immediately  burnt.  Cotton  isalso  em- 
ployed instead  of  sponge,  and  destroyed  in  the  same  way, 
Tbo  external  genital  organs  are  washed  with  the  same 
antiseptic  solution  as  tho  douche. 

In  each  delivery  room  and  lyin^-in  ward  three  baains 
are  provided — one  for  washing  with  soap  and  water  and 
the  other  two  for  disinfection  with  antiseptic  solntion,  one 
for  the  hands,  the  other  for  instrumenta.  Immediately 
before  and  after  touohing  the  genital  organs  of  any  patient, 
it  is  etrictly  enjoined  that  the  hands  and  wrists  should 
first  be  washed  and  afterwards  thoroughly  rinsed  in  anti- 
septic solution.  Special  attention  i»  directed  to  the  nails. 
All  iustrumeuta  such  as  catheters  and  vaginal  tubes,  wheu 
not  iu  use,  arc  coustantly  kept  in  autiseptio  soluiiou.  An 
autieeptic  lubricant  is  also  used. 

It  will  thus  be  seen  that  precautions  are  taken  not  only 
to  prevent  tho  introduction  of  infection  into  tho  hospital, 
but  also  to  prevent  it  from  being  spread  from  ward  to 
ward  or  from  patient  to  patient.  These  precnutions  are 
admittedly  iinpi^rfect  in  certain  particulars.  I  need  but 
instance  the  admission  of  vieitors  and  the  employment  of 
the  same  nurse  in  the  delivery  and  lying<in  wards  in  this 
connection.  It  is  difficult,  however,  to  see  how,  short  of 
liavinfi^  a  separate  room  aod  a  separate  nurse  to  eacli 
patient,  more  stringent  regalations  could  bo  laid  down 
with  a  view  to  prcreut  the  transmission  of  infection  from 
paiicint  to  patient. 

Certain  it  is  that  the  service  of  a  lying-in  hospital 
necessitates  upecial  precautions,  for,  owing  to  the  close 
proiimity  of  piitients,  the  risk  of  conveying  infection  is 
greater  in  nncli  an  institution  tlian  in  private  practice,  where 
they  are  more  scattered,  lint  the  risks  are  precisely  tho 
same  in  kind,  the  difference  is  merely  cue  of  dogreo. 
The  same  principles  underlie  the  methods  of  precaution. 
It  is,  therefore,  an  easy  matter  to  adapt  the  details  of  tho 
one  to  the  practice  of  the  other.     It  is  thus  that  the  scr- 

voi..  xxxii.  19 


270 


fETKB    IK    CBILDBXD. 


rice  of  &a  hoB^it&l  iinds  its  eobo  outside.     In  botb  atri< 
adieaion  to  points  of  detail,  founded  on  a  rational  UDder>l 
stMidin^  of  the  princijjEes  involved,  is  called  for.      With- 
out this,  error  is  liable  to  erepp  in  and  failnre  to  onsuo. 

T]ie  cbarts  before  the  Society  record,  with  greater  accu- 
racy than  any  mere  words  of  mine  can  describe,  what  tn&y 
be  attained  by  attention  to  points  of  detail.  It  is  not  the 
mere  use  of  antiseptics,  but  the  method  of  usiug  them  and 
the  faithful  carrying  out  of  details  oonceraiug  theirappli- 
catioii,  which  calls  forth  their  apcoial  virtue. 

Now,  during  the  whole  period  to  which  these  charts 
refer  the  eame  principles  have  prevailed — ant jseptice  have 
been  in  constant  use,  but  tho  details  Lave  been  changing, 
and  even  now  cannot  bo  looked  upon  m  perfected.  The 
result,  as  far  as  it  goes,  lies  before  you  in  the  facts  which 
I  have  already  presented. 

In  justice  to  others,  however,  I  wonld  point  out  that 
the  present  condition  of  the  hospital  has  resulted  from  an 
ever-increaaing  espericncc,  aTid  ia  the  ftccHoiulative  effect 
of  the  labours  of  those  who  hare  paid  ottention  to  the 
Bame  sabjoct.  The  conditiun  of  the  hospital,  even  at  the 
present  time,  cannot  be  regarded  as  absolutely  perfect. 

It  now  remains  to  consider  the  detaila  which  more  par- 
ticularly pertain  to  the  various  antiseptic  agents  employed. 
It  is  chiefly  with  reference  to  tho  strength  and  character 
of  the  iintisoptic  stilutiouB  that  several  important  chang'es 
have  been  effected. 


The  reading  of  the  remainder  of  this  contribution  vras 
poBtponed  till  the  next  meeting. 


JULY  2nd,   1890. 

AuEiD  L.  <]rALi.BiH,  M.D.,  President,  in  the  Chair. 

Present — 39  Fellows  and  6  Visitors. 

Booka  were  presented  by  Dr.  A.  H.  P.  Barbour,  Dr. 
Lowers,  and  the  London  Hospitnl  Medical  Staff. 

Alfredo  Antnnes  Kanthack,  P.R.C.S.,  nnd  Fredericlc 
John  McCann,  M.B.,  C.M.Edin.j  were  elected  Fellows  of 
the  Sooiotj. 

The  following  gentlemen  were  proposed  for  election  : — 
Richard  Ackerloy,  M.B..  B.S.Oxoii.  (Ashburton)  ;  Arthur 
Norraan  Boycott,  L.K.C.P.Lond.  (Purley)  ;  William  Ilenry 
Laurence  Copeland,  M.B.Cantab.;  Charles.  David  Green, 
M.D.Lond.j  B.S.  (Upper  Edmonton)  ;  David  Berry  Hurt, 
M.D.Kdin.  (Edinburgh);  Harold  Low,  M.B.Cantab. 
(Sydenham);  H.  B.  Osbiirn,L.R.C.P.  [Clapbnm  Common); 
A.  W.  Mayo  Bobson,  P.R.C.S.  (Leeds)  ;  John  WiUiara 
Taylor,  P.R.C.S.  (Birmingham)  ;  WaUer  Tyrrell,  L.B.C.P. 
Lond. ;  Samuel  W.  Whcoton,  M.D.Lond.  (Clapham 
Common)  ;  and  Edvfin  Francis  WTiite,  P.R.C.S.  (Putney). 


272 


DECTDUA  VERA  AND  REFLEXA  FROM:  A   TERT 
EARhY  ABORTION. 


By  G.  E.  Hermait,  M.B.,  F.R.C.P. 

The  speolnien  exliib!tcil  wbb  passed  by  a  nalliparo.  She 
began  to  be  nnwell  Bve  weeks  after  tlie  last  menstrual 
pei-icid,  !in<l  on  tbe  second  day  of  the  flow  complaiaed  of 
great  paJu,  aud  passed  the  fonuation  uow  exhibited.  Dr. 
Herrasn  -was  indebted  to  Mr.  W.  T,  Lane  for  the  speci- 
men. It  cousisted  of  what  looked  like  a  cast  of  the 
uterus,  and  was  evidently  the  deeidiia  vera,  formed  by  two 
triangidar  pieces  of  thick  membrane,  smooth,  but  traversed 
by  many  fine  sulci  within,  rough  without,  and  united  at 
what  corresponded  to  the  junction  nf  the  anterior  and 
posterior  uterine  walls  by  membrane  so  thin  as  to  be  almost 
tranehicent.  One  of  these  pieces  had  been  slit  up  tho 
middle,  BO  as  to  show  the  inner  surface  of  the  menibrnno  ; 
and  on  it,  close  to  the  fnndtis  uteri,  was  a  littlo  cup  of 
membTane  about  large  enough  to  contain  a  pea,  evidently 
the  decidua  rellexa.  The  opeiiiag  of  the  cup  (decidual 
umbilicus)  was  jagged,  as  if  it  bad  been  torn.  The  ovam 
hail  either  escaped  or  wng  too  sniidl  for  identification.  The 
decidua  vera  naa  IJ  inches  k'ug  by  IJ-  wide,  and  ^  of  an  inch 
thick  at  the  thickest  part.  The  decidua  reflesa  seemed 
hardly  thicker  than  paper,  Thci  diameter  of  th©  cup 
which  it  formed  was  about  jj  of  an  inch. 

The  epecimen  tvaii  ia  the  London  Hoapital  Museum. 
Dr.  Herman  was  not  awnre  of  any  specimen,  or  drawing 
of  n  Bpi'cinien,  showing  the  hnm&n  decidua  rcficxo  at  ao 
early  a  stage. 


273 


FCKTUS,  PLACi^NTA,  MKMBEANES,  AND  FALLO- 
PIAN TUBE;  fKOil  A  CASE  OF  RUPTURED 
TUBAL  GESTATION,  COMPLICATED  BY  A 
LARGE  HiEMATO-SALPINX  ON  THE  OPPO- 
SITE SIDE. 

By  C.  J.  Cl'I-LINOWOBTH,  M.D. 

Dr.  CcixiNQWORru  exhibited  a  footoB,  placenta,  niem- 
branoB,  fttid  loft.  FallopiBQ  tube,  from  a  case  «f  ruptupad 
tubal  gpst»tion.  Abdominal  section  was  perfonned  five 
and  a  bn.1f  ilayn  after  the  presumed  ilat«  of  rupture,  and 
the  dingnosis  was  confirmed  by  findmg  in  the  pentoneal 
cavity,  along  vnth  a  large  quantity  of  fluid  blood,  a  foetus 
2i  iuuhes  lu  length,  stdl  attached  to  the  ci^utents  of  the 
uac  by  tho  unruptured  fuuU.  The  placcatu  (which  was 
the  seat  of  au  c3:t«nsiro  baimorrhage  of  older  date  than 
the  rupture,  and  was  therefore  of  interest  in  connection 
with  a  paper  recently  read  by  Mr.  Bland  Sutton  before 
the  Royal  Medical  and  Chirurgical  Society]  was  partially 
Ei'paratod  and  protruding  from  an  aperture  in  the  wall  of 
the  left  tube  measuring  1^  x  1  inch.  The  right  tube  was 
diateuded  with  fluid,  and  formed  n  large,  teuse,  uurup- 
tuied,  obluug  tumour,  situated  behind  thy  right  bruud 
ligament,  and  adherent  orer  ila  whole  KUrfacc.  The  (luid. 
was  viscid  in  character  and  of  a  dark  hrowu  culour, 
evidently  consifiting  of  mucus  and  altered  blood.  Tlic 
effused  blood  and  foetal  producta  had  tho  odour  of  com- 
mcncing  decomposition,  and  the  patient  at  the  ttuic  of 
operation  was  HBptictemte.  Her  condition  fur  tko  lirst 
few  daya  was  uot  promising,  bat  there  was  now  every 
proHpect  of  recovery.* 

*  This  pnticnl  CDiitinuud  to  proitrtiM  ntUfa(!Uir%.  Sliu  Inft  tho  lioii|itLil, 
us  wistks  afUr  the  Ajicntion,  in  gf,r>A  liealtli,  bat  witli  a  ■innU  uuu*,  (till 
dii*chitrglng,  ut  (be  lower  Migic  of  ilie  iuci«ian. 


274 


ECPTUEED   TUBAL   GISTATION. 


Dr.  Hbywood  Smith  asked  I>r.  Cxitliugwortb  whether  he  had 
removpd  the  hteiiiato-salptiix,  anil  whether  lie  had  any  theory  as 
to  the  formation  of  the  hieniiito-salpjini  on  the  right  side,  also 
whether  ite  oncoming  ha<I  njiything  to  do  with  determiuiag  the 
rupture  of  Ihe  oviduct  on  the  left,  as  it  li&d  ruptured  rather 
«arlf. 

Mr.  DoB^AN  was  incliiied  to  beliuvu  that,  id  souke  citaes  at  least, 
the  "  apoplexy  "  o!  an  ovum  was  jiroduced  by  Ui*?  application 
of  the  Hgature  at  the  up«ratioa,  and  consequent  eugorgement  of 
the  vesBels  ou  the  distal  side.  Ecchymosea  and  extravasationa 
were  often  observed  ou  Ike  aurfaee  of  Biuall  ovarian  tumours 
ahao&t  immediately  after  tightening  of  the  ligature,  and  before 
the  8UTg«ou  had  time  to  cut  through  tli<i  pedicle.  If  such  an 
accident  could  occur  in  a  cyatlc  tumour,  where  the  vessels  were 
usually  normal  and  healthy,  it  must  be  much  more  jirobabJe 
and  frequent  in  the  ease  of  af<Btal  cyst  of  the  tube,  where  the 
veBHtjla  wwre  in  many  respects  ahuormiil  and  diseased. 

Dr.  CcLiiNGi WORTH,  in  reply  to  Dr.  Heywood  Siiiitb,  said 
that  the  patient  hsid  migsed  two  menstrual  periode.  and  that 
fact,  together  with  the  length  of  the  foetus,  seemed  to  iodicate 
that  the  pregnancy  had  reached  the  begbiniug  of  the  third 
month.  He  had  not  as  yet  heen  abEe  to  traee  the  history  of  the 
hffimato-salpinx  of  old  standing  on  the  right  side  which  he  had 
found  and  removed  along  with  the  adjacent  ovary.  With  regard 
to  Mr.  Doran's  reniart  as  to  the  possibility  of  the  clot  in  tha 
placenta  having  formed  as  a  couseq^uence  of  the  application  of 
a  ligature  at  the  operation,  be  felt  sure  that  any  candid  and 
carefnl  observer,  looking  at  the  speeinien,  would  see  that  such 
au  (explanation,  in  this  partieular  case,  vrm  entirely  out  of  the 
question.     The  clot  was  quite  old. 


275 


FEVER  JN   CHILDBED. 


Part  I. — Gevbr&l  Hygieni  amd  Antiskpsib  (eoniinued). 
By  RoHjjKT  BoxALi,  M.B.,  B.C.Cantab.,  M.R.C.P.Lond., 

ISUBTAUT  OBSTBTBIC  PHJBtOUK   TO,  AND   ISCITEEB  OS  FHAOTIOJU. 
UIUWIVICKY  IT,  TBS  UlilbLBSItX   HOliPITAU 

<It«celved  Dccembor  10th,  ISSS.) 

(Abatract) 

IV,  The.  eompanitive  value  vf  various  antlnepUc  ogmiin } 
antiteplicH  of  the  carbulic  and  Ci/ndy  era;  ndvantage 
of  stihltmale  over  carholic  acid  and  Oondy't  jlnid — 
rhemiral  inronLpatihilify  of  the  latter;  (fradual  decline 
of  eeptic  iiilfuence  efi'ded  hy  syetematic  attcfition  to 
pointe  of  general  hygiene,  and  by  tht  progreitsivB  elaho' 
ration  of  antiseplic  detaile. 

Tliv  partivukr  antiiibpUo  ugouts  wluvh  liavc  bccii  useil  at 
diftwn'iit  parts  of  the  period  now  under  coasideratioii  jire  given 
iu  Tablb  III,  anil  arc  uW  rougbly  iudicatt.'d  on  Cbart  m. 

Thia  »how9 — 

(1)  That  the  marked  improvement  which  occurrfd  in  Maij,  IRBl, 
coincided  in  point  oftivie  Kith  the  sahntituttmt  of  sublimafffor  car- 
holic acid  and  (hndi/'i  jtuid  at  the  general  andaepttc*  emphyed. 

(2)  That  the  gradual  decline  of  teplio  injlunicc  which  preceded 
that  dale  atat  tffected  leithout  chanijc  in  iKt  antiteptie  emplcyej. 

The  antis«ptt08  usnil  during  the  carlwlie  and  Con<ly  era  are 
coi)«i(ltn?(i  in  detail, 

Tbp  Waring  oE  the  clieuiical  tiicoiiiimtibilltv  of  tho  agents 
Biaploycil  during  the  cnrboUc  Uud  Coudy  era  is  discussed. 

The  gnidual  dflchne  of  septic  itifliienoe  obwrvod  during  th« 
later  moaths  of  that  en,  i*  attributed  in  part  to  tbo  oudeuvour 
whicli  waH  at  that  time  made  to  obriato  the  reduction  of  the 


276 


rKVKK    IS    CaiLUB&D. 


pcrm&ngaDatc  in  tLt.-  solution  employed  iov  washing  and  doucbing 
thti  ]>uttcut,  and  in  part  to  the  greutei*  efficiency  of  tbo  iniilwivea 
and  niirges,  owitig  totbuadoiftioaof  definite  rules  und  directions 
for  their  giiitiaiice. 

It  ia  rema.rked  tbiit  bho  &j8t«matic  application  of  general 
hygienic  and  autieeptic  miea  to  the  aervicc  o£  tlie  iuetitutiou,  not 
only  lod  to  a  gradoal  reduL-tiou  in  tlie  fxe^uency  and  virulence 
of  general  septic  iJlnesa,  of  jvelvic  iuflatun)utiuiui,of  imhoattby 
lesions  of  the  gcnitiUs,  and  of  mammary  iuftammatioiiit  and  of 
cases  of  C}'atitU  aiiioag  tlie  [juerpem;  but  at  the  same  time 
effected  a  decrease  in  the  cases  of  ptiriilcnt  ophthalmia,  of  offen- 
sively diwharging  navel,  uf  tlii'neli  in  infants,  and  of  abscesBes 
on  the  fingers  among  the  nurges. 

It  18  concluded — 

(1)  Tliat  the  gratluat  decline  in  leplie  injlucnce  obterireJ  in 
thf  earhf  monlhii  of  1S.S4  tons  hrou^ht  about  in  part  by  st/gt/rmalitl 
af  tent  ion  to  pointt  of  ^rneral  hiigitt\e,wore  particularbjon  ihir  pari 
of  the  midiaivrsantl  nuricH.and  in  ■pari  htf  the  progressive  ftabora- 
tivn  of  drtaih  concermni/  the  mm  of  thu  antisdptict  employed. 

(2)  That  thr  marked  itnproitemfint  lehich  took  place  in  May  of 
the  same  yrnr  irax  eff'eisted  in  part  liy  the  »iih»titulion  qf  tublimate 

for  curhoUc  acid  and  Condi/^ k Jluid  at  theijeneral  antisvptict  in  utt, 
and  in  part  itf  the  continuance  of  the  name  beneficial  injlueneea. 

CVrtaiu  relafses  wliivli  have  taken  place  siucti  that  dalu  will 
be  dealt  with  in  Section  V, 


In  this  and  tlio  following  section  the  autisoptic  agents 
iu  uso  at  diffci'out  parts  of  the  period  now  antler  con- 
Bider&tlon  will  be  indicated,  and  their  relative  value  dia- 
cnased. 

In  estiiDHting  their  relative  value,  the  death-rate,  the 
general  fever-rate,  and  abovo  all  the  septic  rate  afford 
useful  data.  To  the  close  relation  of  these  several  factors 
reference  has  already  been  made.  Other  indications  off 
the  decline  of  septic  influence  will  he  given  iu  tbissecfcioa. 

It  wiU  be  shown — 

(1)  That  the  marked  improvement  which  occurred  in 
May,  mS4,  coincided  in  puint  of  time  with  the  eubatitu- 


877 


tion  of  Bublimato  for  carbolic  acid  and  Coudy'8  Raid  as 
the  general  antiBeptics  employed. 

(2)  That  tlio  gradual  decline  of  septic  inflaeace  which 
preceded  that  date  was  effected  without  chanfrs  in  tlie 
antiseptic  employed. 

It  will  be  further  demonstrated  that  two  elemeuts  have 
combined  to  bring  about  this  result.     These  are — 

(1)  Syetemhtic  attentiou  to  points  of  general  hygiene, 
more  particularly  on  the  part  of  the  uiidwJree  and  uurees. 

(2}  Progressive  elaboration  of  details  couoorning  the 
use  of  the  antiseptics  employed. 

It  will  be  pointed  out  that  these  elotnonts  being  estab- 
lished before,  have  continued  in  operation  throughout  the 
sublimate  period,  and  on  that  account  cannot  be  di»- 
regardtfd  in  eatimatiug  the  value  of  sublimate  as  compared 
with  cai-bolic  acid  aud  Coiidy's  fluid.  Nevertheless  the 
elimination  of  septic  iuHueuco  at  that  time  waH  so  cumplulu, 
and  has  bei-n  no  perHi»tentl\*  maintaineil,  a»  to  establish 
fully  the  surpassing  ralae  of  sublimate  as  an  antit^eptic. 

Hitherto  I  have,  in  dealing  with  the  service  of  tho 
hospital,  oiftrcly  indicated  the  broad  fact  that  autiseptica 
wcro  employed  for  the  hands,  for  instruments  and  ntonsilg, 
for  washing  and  douching  the  patient,  and  for  lubricating 
purpoHGti,  but  I  must  now  uieutiou  the  particular  ageuta 
which  have  been  nsed  for  these  several  purposes  at 
different  parts  of  tins  tteptennial  period.  They  are  given 
in  the  following  table  {Table  III,  p.  284),  and  are  also 
roughly  indicated  on  Glinrt  III. 

Until  the  begiiininpr  of  May,  1884,  both  phenol  and 
penuanguuiktu  of  putas&ium  were  employodj  and  from  that 
time  onwards  porchlorido  of  mercury,  and  for  the  most 
part  perchloridc  of  mercury  only. 

It  IB  instructive  to  observe  bow  closely  variations  in 
the  condition  of  the  hospital  followed  changes  made  in 
the  antiseptics  employed.  1  have  already  stated  that  the 
sudden  fall  in  the  fever-rate,  which  followed  the  siibstitu- 
tion  of  sublimate  for  carbolic  acid  and  Condy's  fluid  wafi  in 
the  maiu  due  to  the  practical  abolition  of  septic  influence. 


276 


rxriR    IN    CBILDBEU. 


The  relative  value,  then,  of  these  agents  as  antineptics 
finds  expression  in  the  pyrexia  chart,  though  not  to  sacfa 
an  extent  as  mi^ht  be  at  firat  sight  supposed.  For 
though  the  aublimato  shows  an  immediate,  considerable, 
and  Bustnined  advance  on  the  carbolic  and  Condy  era, 
causes  other  than  the  mere  change  of  antiseptio  were 
already  working  in  the  same  direction,  and  ever  since 
have  cOQtinuod  to  exort  the  same  beneficial  in:9aence. 
These  causes  I  shurll  have  occasion  to  specify  ppoaently,  and 
to  point  out  the  part  which  they  played  in  effecting  this. 

But  in  any  case  the  improvement,  taken  as  an  index  of 
the  efficacy  of  sublimate  as  compared  with  carhob'c  acid, 
and  more  particuhirly  of  sablimate  aa  compared  with 
Condy's  fluid  requires  to  ha  considerably  diaoountod,  for 
reasons  which  will  immediately  appear. 

To  one  matter  of  detail  it  seems  to  havo  been  reserved 
for  tne  to  direct  Bpecial  attention,  I  allude  to  the  incom- 
patibility of  the  chemical  agents  employed  as  antiaeptics. 
I  must  refer  to  my  original  commHuieation*  for  particulars  ; 
it  is  antHcLent  for  the  preseut  purpose  to  state  that,  taking 
corrosive  sublimate,  carbolic  acid,  iodine,  t;alicytic  actd,  and 
Condy's  fluid  as  examples,  I  show'ed  that  many  iustancea 
occurred  in  which,  when  brought  into  contact  oue  with 
anolher,  or  with  certnin  lubricants,  chemical  action  took 
place  -,  aud  I  here  reproduce  the  annexed  tabic  for  purposes 
of  reference.  The  crosses  in  the  table,  which  occur  at 
certain  intersecting  points  of  the  horizoutal  and  vertical 
columns,  indicate  that  interaction  takea  place  betwcoo 
the  agents  which  stand  at  the  head  of  those  columns. 
In  condemning  these  admixtures  as  chemically  incom- 
patible, I  am  prepared  to  admit  that  iu  some  iustanoes 
the  newly  formed  compounds  may  possibly  be  powerfal 
antiseptics,  though  this  remains  to  be  proved;  and  1 
would  submit  that  any  observations  made  with  a  view 
to  determine  this  point  are  prEictically  valueless,  uoleaa 
either  these   newly  formed    compounds   be   isolated    and 

•  '■  Tliu  Clit'initril  liicoin[jiiiibllilj  of  Antiseplii;  Agents."  '  Brit.  Ued. 
Jouni.,'  vol.  i,  1888,  p.  898 ;  nnil  '  Lnncot,'  vol.  ii.  1888,  li.  Oas. 


FBTES    n<   OHILDBID. 


87V 


used  in  pure  solution,  or  tlie  admixture  W  made  !□  such 
proportiou  thut  nt  least  u»  apprecioblo  esceefl  of  eitbur 
one  or  otlior  of  the  original  antiseptic  coostitaents  be 
laffcTod  t^3  romnin  in  the  tost  solutions  pmployad. 


X 

a 

8 

8 

k 

s 

C 

a 

s 

1 

1 

H 

M 

K 
M 

1.  CorToslte8ablimMteSolutii>n(PM-l 
chlnride  of  Mcrror^]        .        .  ) 

S.  Otliolic  Botvt'ion  (Plmnol)  . 

5.  lodLn«  Solntion  (Iodine  mid  Iodid«  1 

of  PnUuMintn) .        ,        .        ,  J 

4.  IJNlicjlii;  Sulalion  (Salicylic  Acid) 

6.  Oonilj'i  Fluid  (P«nuHug«iiKte  of  1 

Potvwiutn)      ,        (        *        .J 

N 
K 

X 

We  proceed  now  to  consider  the  antiseptics  of  tHo  car- 
bolic and  Condy  era. 

Prior  to  May,  l884j  carbolic  solution  (phenol  1  in  30} 
was  employed  for  hnnda,  for  iiietrunionts  and  uteuHilgj  both 
at  the  timt'  of  delivery  and  during  the  lying  in  ;  for  douch- 
ing and  washing  the  patient  both  carbolic  and  Condy  were 
employed  (phenol  1  in  40,  permanganate  of  potRssinm  1 
in  80()0  =  Condy's  fluid  3J  to  Oj),  the  latter  before  labour 
and  in  the  lying-in  wards,  the  former  for  the  first  douche 
after  labour  only — if  even  a  second  were  required  in  the 
delivery  room  Condy  was  snbstitatod ;  for  lubrication 
carbolieed  lard  (1  in  20)  was  used  until  Jnly,  1883,  when 
carbotiaed  oil  (I  in  20]  was  substituted  and  used  for  that 
purpose  both  during  parturitiuu  and  puerpery. 

Into  this  arrangement  the  importance  of  the  chemical 
incompatibility  of  the  agents  employed  intruder  itsself. 

Ah  wo  are  now  denling  with  points  of  detail,  1  shall  dis- 
pose of  the  least  important  item,  the  Inbrioant,  first.  Now, 
carboliaed  oil  (and  a  similar  criticisui  applies  to  carbotised 


280 


rETBB  nr  cuilsbbd. 


Inrd)  IB  little  if  at  d.11  gtipGrioi*  from  an  antieeptio  poini 
view  to  olive  oil  alono.  To  my  mind  it  is  a  matter  of 
little  importance  whether  the  luhricant  be  antiseptic  as 
well  as  aseptic,  provided  whatever  it  may  he  used  to  lubri- 
cate he  previously  reudered  aseptic.  But  carboliaed  oil, 
through  its  supposed  autiaeptic  property,  engenders  a  false 
scna&  of  security  whicL  is  apt  to  lead  to  the  otuiseioQ  of  this 
very  precaution — to  the  disregard  of  more  efficient  out- 
works bpcause  it8  own  position  is  considered  iniprog'Dablo. 

But  even  this  is  a  inp.tier  of  secoudnry  importaBco  wbon 
it  iit  couiiidered  tliat  carbolised  oil,  liko  both  tho  carbolic 
acid  aud  olive  oil  from  wliicli  it  is  made,  destroy  penuau- 
ganate  oFpotassiuiii.  Add  to  this  the  Fact  thnt  Ihe  passages 
were  saturated  6rst  with  Coudy's  fluid,  ilivn  with  carbolic 
acid,  and  then  with  Condy's  fluid  ag&iti,  and  that  it  was  the 
rule  to  Goak  the  hands  and  instruments  in  carbolic  liolatioD 
before  touching  the  genitals,  and  the  additional  fact  that 
a  very  little  carbolic  will  reduce  n  relatively  large  quantity 
of  Condy  solution  (1  part  of  I  in  20  phenol  solution  will 
turn  brown  nt  least  l:i()(.l  pitrtH  of  1  in  HOOO  permnnganntc 
solution),  il  may  be  judged  that  this  imitnal  destruction 
of  tbf  ageiit«  employed  often  led  to  the  total  annihilation 
of  the  Coudy's  Buid,  aud  thut  the  system  of  antiseptics 
was  thereby  reduced  in  efficiency. 

MoreovLT,  through  the  mere  fact  that  the  game  douche 
apparatuH  was  used  for  both  solutionis,  and  that  thova.ginal 
pipes  were  constantly  kept  in  carbolic  solution  when  not  in 
usoj  it  happened  that,  when  I  first  became  connected  with 
the  hospital,  the  permanganate  in  the  douche  was  as  often 
as  not  completely  reduced  before  any  of  it  was  brought  into 
contact  with  the  genital  passagesj  so  that  septic  niattoi- 
was  afforded  a  ready  opportunity  of  forcing  the  position. 

It  WHS  our  coDstiint  endeavour  to  prevent  this,  nod  to 
insist  that  no  Condy  douche  should  be  given  which  had 
already  turned  brown,  and  that,  when  given,  it  should  be 
continued  until  it  returned  unchanged  in  colour.  To  the 
uieaeure  of  succeus  which  atteaded  thL-so  injunctioua  may,  1 
think,  in  part  at  any  rate,  be  attributed  the  declension  in 


FEVEB    IN    CMILDBBD. 


281 


the  fever-rale  at  tlie  beginning  of  1884,  a  gradual  decline 
reBultiu<^,  as  I  hare  already  sliowu,  almost  entirely  from  a 
diintQutiou  of  septic  influence,  which  froLa  flrst  to  last  is 
as  great  us  that  wbich  immediately  fellowed  the  introdnc- 
tion  of  sublimate. 

The  foct,  nevoi'theless,  vemnius  thnt  during  the  greater 
part  of  the  carbolic  &nA  Coudy  era,  owing  to  their  tnutual 
antagonism  which  tbey  bad  «?ery  opportunity  of  exorcis- 
ing, neither  the  perinimganate  nor  tlie  carbolii;  were,  ho 
to  speak,  allowi-'d  fair  play.  The  permanganate  being 
used  in  woak  Hulution  euifefed  most  severely. 

But,  in  addition  to  tbie  defect  in  the  regulations  then 
in  vojfue,  auotber  important  consideration  demands 
attention  as  conducing  to  the  decline  in  the  general 
forer^ratc  during  the  later  mouths  of  the  pre-snblimate 
period. 

For,  even  had  the  regulations  possessed  no  flaw,  it  was 
impossible  at  chat  time  to  insnre  faithful  adhesion  to  Boch 
as  existed,  considering  thnt  no  systematic  instrnctions 
wc-rf  avttiUblo  for  the  guidance  of  the  nurses.  And 
especially  doeis  this  become  a  matter  uf  importoitce  in  an 
institution  conducted  on  the  Hues  of  the  General  Lying-in 
Uoupital,  iu  winch  the  patients  are  all  attended  by  mid- 
vrives,  and  nursed  by  women  who  are  undergoing  a  course 
of  two  or  three  montbs'  training  with  little  or  no  previous 
hospital  experience.  When  the  ease  with  whicb,  in  such 
hands  ns  these,  tbe  chain  of  rigid  asepticism  is  liable  to 
be  snapped  asunder  receives  due  consideration,  it  is  possible 
to  gauge  the  advantage  to  be  derived  from  a  systematic 
method  of  working  with  u  definite  code  of  precise  rules 
Bnd  directions,  from  which  no  departure  sliould  be  allowed. 
When  I  cnttTL-d  on  my  duties  as  House  Physician  in 
September,  18tJ3,  no  such  method  prevailed,  and  it  was 
then  possible  to  predict  with  no  little  degree  of  certainty 
how  the  patient*?  admitted  to  any  particular  ward  were 
likely  to  fare  by  the  extent  to  which  the  nurse  in  cbargo 
had  mafitered  the  details  of  antiseptic  midwifery.  At  that 
time  temperatures  of  104''  F.,  10.i°  F.,  and  106°  F.  were 


2S2 


PSV8B    rK    CaiLDDCS. 


oomnoon  incidents ;  a  normal  tempera-tupc  throughont  the 
puerpeTium  was  quite  tlie  exception. 

But,  as  I  liave  already  shown,  dnring  tbe  early  montlia 
oi  ISd^j  clespite  llie  occurreuce  of  scarlet  fever  cases,  a 
very  considerable  improretneut  iu  tlie  septic  rate,  and 
consequently  in  the  general  fever-rate,  occurred ;  an 
improvement  which  is  so  steady  and  persistent  as  to  stand 
out  in  strong  contrast  with  tbe  sudden  rises  and  falls 
which  precede  it,  and  which,  even  before  the  introdaotion 
of  sublimate,  reduced  the  septicity  and  febrilitj  to  a 
point  not  previously  reached. 

This  was,  I  believe,  in  no  small  measure  attribntablo 
to  the  introduction  at  tha,t  time  of  definite  rules  for  tbe 
guidance  of  the  hospital  sta:ff.  As,  during  the  &an)o  time, 
the  details  of  antiBeptic  treatment  were  one  by  one  elabo- 
rated,  these  regnlfttious  advanced  in  completenesH.  Their 
syt^tematic  adoption  led  to  a  great  advance  iu  the  ofBciencjr 
of  the  nursing  staff  thtoughoufc  the  hospital. 

Stadfelt,  of  Copenhagen,  has  expressed  his  btlicf  that 
"  the  hygieno  of  a  Maternity  depends  leas  upon  its  con- 
struction aud  upon  ita  age  than  upon  the  hygienic  prin- 
oiptes  npon  which  it  is  directed,  and  on  the  perBevernncc 
with  which  theHe  principles  are  carried  out  in  the  duily 
service."      This  opinion  I  emphatically  endorse. 

1  have  shown  that  one  of  the  most  considerable  improve* 
meuta  which  took  placs  during  the  seven  years  occui-red 
in  the  early  months  of  1884,  before  the  sublimate  era 
dawned.  I  have  stated  that  no  structural  idterutions  had 
been  made  during  the  whole  of  that  time.  I  have  recorded 
the  endeavour  which  was  then  made  to  systematize  tbe 
service  of  the  institution  upon  hygienic  principles.  That 
the  endeavour  has  been  attended  with  a  great  measure  of 
Buccess  cannot  be  denied.  For  not  only  were  Bcptic 
illnesses,  pelvic  inflammations,  unhealthy  lesions  of  tbe 
genitals,  and  I  think  I  may  add  mammary  inSammations 
as  well  as  case*  of  cystitis  among  the  puerperse  gradually 
reduced  in  frequency  aud  virulence  during  the  last  phase 
of  the  carbolic  and  Condy  era,  but  at  the  same  time  cases 


FKITEit    m    CBlLDiJEU. 


of  purulent  oplitlmlroia  auil  t»f  offeiisively  discliarging 
narcl,  as  well  as  of  tbrush  in  children  aod  of  abBcessea  oa 
the  fiagers  among'  the  curses,  diminished  in  number. 

Tliis  can  mean  one  thing  and  one  thing  only — that 
septic  iufluencu  wasoutlie  wane  even  before  tlie  sublimate 
era  commenced. 

Having  now  considered  in  detail  the  decline  in  the 
death-rate,  in  the  general  £ever-rate,  and  in  the  septic  rate, 
and  also  the  changes  which  have  been  effected  in  the 
eerrice  of  the  hospital,  I  wonld  present  the  following 
general  concluaiooB  : 

(I]  That  the  gradual  decline  observed  in  the  early 
months  of  1884,  was  brought  about  in  part  hy  Bystemntio 
attention  to  points  of  general  hygiene,  more  pnrticularly 
on  the  part  of  the  midwives  and  nurses,  and  in  part  by 
the  progressive  elaborntiou  of  details  concerning  the  use 
of  the  antiseptics  employed. 

(2)  That  the  marked  improvement  which  took  place 
in  May  of  the  Bame  y^ar,  was  effected  in  part  by  the 
substitution  of  auUliniHte  fur  carbolic  acid  and  Condy's 
flnid  as  the  general  antiseptics  in  uae,  and  in  part  by  the 
OODtiouance  of  the  eame  beneficial  influences. 

Having  now  ascertained  what  may  be  termed  the 
normal  condition  of  the  hoBpital  for  each  of  these  periods, 
&□  opportunity  is  presented  of  conHidering  the  effect  pro- 
duced by  other  influences.  These  will  be  discussed  iu 
the  remaining  sectioOB  of  the  paper. 

In  the  following  section  certain  relapses  which  have 
taken  place  Trill  be  considered. 


niTicB  w  cHirnBBn. 


885 


V.  Antineplicn  vf  the  xuhfmate  era;  inea»itre/i  tnken  to 
prevent  deterioration  of  tite  solution;  infRTionty  of 
jialufrr  nji  ramjiurftl  icith  ttihliviate ;  advontaijt  of 
antUepti<-  over  mere  clfanltf  viensure^  ;  value  of  strong 
tlouehe-solutioiui  as  compared  teUh  those  of  weak  anti- 
septic power  and  of  no  antisejttic  powtr. 

{Reee'ivei  Doeenbn  lOtli.  ISSO.) 
{Ahxtrnrt.) 

The  autiacptics  used  during  the  sublimatQ  era  ar<?  coaaidcrod 
in  dvtail. 

The  iDHasurps  iaVen  to  preveut  d<'ti>rioriitiou  of  tlie  soIuLioa 
arc  <]tHcu880tl. 

It  is  jjotiited  out  that  aeitlier  more  geuci-al  bjpicnic  mea- 
8ur*>8.  iior  llio  aoiiiLioii  om|>li>yo(l  (or  tho  hiintls.  inBtriimcLts, 
Ao.iior  Ihi'  lubricant,  hiivc  auffi*rt'(l  appreriaMp  viLi-iiiLiun,  and 
tliat  tlie  Holiitinn  einploj'ed  for  waaliing  and  douchiug  the 
geniLnta  has  been  the  only  variable  eleuivnt. 

Attention  is  also  drawn  to  tlie  fallowing  facta — 

(1)  That  as  no  change  htis  been  miido  in  tho  method  of 
aduiiuiBtcriug  tlio  doucho,  its  niechaiiical  and  ocbolic  oCE<.>cts 
have  reinaiaeil  unimpaired. 

(2)  Tbiil  EU)  the  strcuglh  and  character  uf  the  antiseptic 
ogODt  cmploj'vd  iu  the  doQcLe-solutiou  lia«  bccu  tho  onlj' 
▼ariabl«  factor,  correHpouding  variations  in  the  condition  of  the 
lio^tt43  afford  <-vidou<.'c  of  their  coni)inrsttve  valuo. 

Such  variations  aw  shown  to  have  taken  [ilare;  for  whvu  the 
sublimate  douche-sulutiuu  wiui  reduced  in  strcngtlt,  and  again 
whi-D  tho  ttublimate  douche- solution  was  replua'd  hy  salufc^r.  the 
ideath-ratt"  rose  and  s^pticoeiuia  reasserted  its  inHuence.  It  is 
reniari£ii.b]^  that  the  only  thrw  di-atha  wbieh  have  oL-curred 
from  svptic  poisoning  during  tlie  \-a»1  &vo  yea.n  should  bare 
taken  place  in  the  two  short  intervals,  amounting  togelher  to 
less  than  tvelve  wcvkH,  during;  which  thoae  Holutinna  were  UML-d. 
The  period  during  which  Milufcr  douehcn  wore  employed  ia 
coQiiidered  in  detail. 

TOL.  XXI II.  20 


286 


raVRR    FN    OHILCBBD. 


It  is  pointed  out  that,  as  saltifer  whb  commonwd  in  the 
middle  of  one  tind  diacoutiuiied  iu  tLe  mitlilte  of  iLOother  month. 
Hie  advance  in  tlie  furer  rate  aad  in  thtt  septic  rate  does  not 
allow  to  the  full  extent,  when,  ah  in  the  forgoing  ehnrtfl,  all  the 
eases  for  each  month  are  iaoluded. 

Table  IV.  however,  unmistiikably  indicjttcB  a  retrograde 
eondition  of  ilie  hoHpital  ilurinE  the  eight  we^Vi*  of  salufer 
<IoucIiinp  a.s  coinimred  with  the  fortnight  which  ininiediately 
preceded  and  which  tmrnodintply  fallowed.  Compn.ro  itlxo  the 
figures  given  iu  Table  IV  with  those  fnven  in  the  hwodJ  colanin 
of  Table  II. 

Til  is  ahoWH — 

(1)  Tiat  thr  death-rate  ros«,  dntijrcm  g^ptic  poitOning. 

(2)  That  the  proportion  of  labours  followed  fty  fevitr,  and  f»pt. 
daily  by  septic  fiver,  incr^atrd. 

(3)  'JViaf,  in  thefi^hrile  oaf  us,  both  the  average  duration  and  tke 
average  height  ofthofvper  increaacd. 

(t)   That  both  the  central  fever-rate  ajii  septic  rat*  advanefi. 

Further,  iu  virtue  uC  Ihiii  result,  tl  ie  probable  that  had  the 
■obUiDatie  not  oiil^  of  the  douche. solution,  but  alto  uE  that 
employed  for  the  hands,  iuati-umentfi.  Ac,,  aud  of  the  lubritant, 
been  replaced  by  gtiltifer,  iiud  had  ealuferbeeo  used  in  all  caat-s, 
instead  of  in  these  ouly  in  wbioh  danger  wns  leiist  to  bo  feared, 
the  effeL't  wuuld  have  been  stiU  more  diiafitroiiii. 

It  is  concluded — 

Thai  taliifcr  is  inferior  to  tiublimair  na  «n  antiseptic  ayent. 

Iiicideatally  (.■vidonev  hue  bvtu  afforded — 

(1)  Of  the  value  of  douahfi-solutionit  nf  strong  over  th&te  of 
fMak  nntiaeplie  power. 

(2)  Of  the  value  of  antiseptic  over  mere  aaeptie  dottch*' 
Bolafians. 

The  routine  ubc  daring  puerpcry  of  weak  antisniitie  or  of  mere 
aseptic  douche-ftnlntiona  is  dep'"eeated. 

By  way  of  explanation  the  su^estion  is  put  forth  that  septio 
material  eollected  about  the  vulva  may,  in  ailniiuiBtering  the 
donch'-,  be  carried  into  tlie  iit-erine  cavity,  where,  cscapiDg 
iminedinte  deBtruction,  it  is  liable  to  become  absorbed. 

/( it  conchidecl — 

That  -unlfga  avch  an  antiseptic  natiition  be  uaed  ait  iit  eapahle  of 
ejftelttally  and  rapidlij  de4(royin</  teptie  vmterial,  and  uhIcmii  the 


ncnCR    TN    CmiTlBRO. 


287 


(oieriuti  genitalt  be  carefully  waniitd  bc/orehajid  tvUh  a  similar 
ift/u/ion,  the  routine  emplotfment  of  the  dmteke  dv-rin^  ■puerpery  ie 
liable,  frcm  the  danger  of  nnavni^nhly  introducing  geptin  maiiwial, 
to  he  atieniled  with  positive,  danger  to  tlui  patient,  and  that  under 
etteh  circuviirtaitceg  H«  tuechn-nical  and  rcholic  ti-dvantages  may  be 
mere  than  eottnterbalitnced  hy  Us  want  of  eejma-deetrorfing  power, 

Suftinii'nt  evidonee  has  been  prodHoed  to  show  that  even  with 
tbiJ  routine  ub(>  of  etrocg  Hublimate  solution  the  danger  still 
lies  ItiHx  iu  inerciLruLlism  tlia-u  iti  sepHis. 

It  it,  Ifierrfare,  concluded — 

That  unle*f  and  vntil  the  maaijold  aottretsa  of  eeplie  infection 
«an  be  ^aeed,  and  vHk  eeHainly  rf/wH  loith  ovifiide  (he  body,  the 
rontint  employment  nf  the  dovehe  needs  nc  defence. 

Beu-souH  fur  rojfariliu^t  (liu  Coiid;^  duucLe  of  the  jire-ftub- 
liraate  period  as  aii  element  of  dimger  axp  luldiiccd. 

Finally,  tho  direct  locul  effect  of  the  difforont  antiseptic 
agents  on  the  tissues  of  the  body  is  considered. 

It  is  corit'ludijd — 

That,  though  this  qtitttion  mnt/  hove  c^ff'rcted  to  tovte-  degrre  the 
comparative  result*  ohiaified  htf  carbolic  acid  and  stilUmale,  it 
i^et  net  affect  the  value  of  the  evidence  which  has  been  aJiluced  in 
tupport  of  the  inferiority  of  weak  sublimate  andofsalufer  douche' 
telution*. 


In  this  soctioii  cortaiu  relapses  wliich  faavo  takcD  place 
since  tlio  iutroduotioa  of  sublimate  will  be  dealt  wttb. 
It  will  be  sliowu  ttat  one  of  tliesa  relapses  was  definitely 
(issociated  with  the  Hubstitution  uf  Halufer  for  Kiibliniiit? 
in  the  solution  nned  for  wanhing  and  doiiohiiig  tbo  pntient» 

Incidentally  evidence  will  be  afforded  of  iho  valae  of 
antiseptic  over  mere  cleanly  menaures. 

I  proceed  iirst  to  a  consideration  of  the  nntitiQptics  of 
lh«  Hubliumte  era. 

Since  May  Ist,  1884-,  eublimato  solution  (porchloride  of 
mercury  1  in  lOUO)  haa  been  employed  witliout  interrup- 
tion for  the  hands,  for  instrnnienta,  &c.,  and  a  eohition  of 
Boblimate  in  glycerin?  of  corresponding  strength  for 
lubrication. 

Throughout  tho  groflter  part  of  the  time  sublimate  sola- 


268 


wy:7V.it  IN  OniLDniD. 


tiooB  bare  also  been  employed  for  wnehinjr  miil  doachinp 
the  patient,  l)ut  tbo  etrength  of  those  has  varied. 

At  first  1  in  2000  solutions  were  need  before  and  after 
labour  in  tlio  dolivery  rooms,  and  iu  the  lying-in  wards. 

Owing,  however,  tu  the  freqnont  inoidonco  of  cases  of 
mercnrialismj*  and  mave  particularly  to  the  fatal  case  in 
wliich  mercurial  absorjition  played  so  promiuenb  a  part 
(see  Fatal  Case  ft,  p.  257),  from  2i3t  Septpmber,  1885,  until 
the  Htli  of  tlie  following  month,  the  douche  given  in  the 
lying-in  wnrds  was  reduced  to  hiilf  the  Bti*eugth  (1  iu  -1000) ; 
but  that  in  the  delirery  room,  given  botli.  before  and  iin- 
loedifltely  after  labour,  remained  the  &amc  ns  before  (1  in 
2000) .  Under  this  practice  a  death  from  septic  phlebitis  and 
general  pyieniia  suuii  oceurred  (see  Fatal  Caso  10,  p.  257). 

In  consequence  of  this  from  14th  November,  188-'),  the 
stronger  douche-solution  (I  iu  2000)  wa.s  contiuned  for  the 
first  four  days  after  labour,  the  weaker  (1  in  4000)  being 
substituted  only  at  the  end  of  that  time.  Tlii^  practice 
was  coutinned  until  the  end  of  the  following  June. 

In  July,  1886,  owing  tn  the  fact  that  the  sublimate 
douche  givoii  before  delivery  tended  rather  to  constrict 
the  tissues  of  the  cervix,  it  was  omitted  and  Coudy  sub- 
stituted (perraauganate  of  potassium  1  in  8000).  At  the 
sumo  time  the  Bublimate  douche  given  immediately  aft«r 
labour  was  increased  to  I  in  1000 ;  that  given  during  the 
firat  three  days  of  tho  puerpenum  (1  in  2000)  and  after, 
wards  (1  iu  4000)  remained  the  »ame.  If,  however,  nny 
suspicion  of  mercurialism  occurred,  Condy  was  at  once 
substituted. 

Such  substitution  has  been  rarely  called  for,  more  par- 
ticularly since  the  beginning  of  1887  when  the  douche 
given  immediately  after  labour  roverfcod  to  the  original 
strength  (1  in  2o6o).t 

This  practice  has  continued  until  the  present  time,  ex- 
cept for  eight  weeks  in  1888 — from  the  middle  of  August 

•  S*>  Dr.  Diibin'^  pajn-r  on  "  MKrciirUIUtii  Iu  L/ing-in  Womtn,"  'Obatct. 
Trnim.,'  vol.  xxviil.  IBHB.  p.  281. 

f  Fur  mtm  nf  uiiTi'iiiiiiliiiri  xro  '  Ubntft.  Traiiii..'  vnl.  %xt,  1888^  |t.  320. 


FEVBK    IN    CBILDIililU. 


289 


until  tlie  middle  of  Octobei- — wlit-u  salufer  solution  (silico- 
iluorido  of  syJa  I  in  SOU  =  gr.  xx  to  Oj)  was  used  for 
wushing  and  douching'  tbo  piiitiont'>  both  in  the  deliveiy 
rooms  and  lying-iii  wards,  in  nil  cnses  where  tliere  was  uo 
special  rcaaon  to  fear  infection. 

But  during  this  short  timo  two  deaths  occurred,  tho 
second  being'  from  hospital  gangrciio  {son  Fatal  Caee»  13, 
14,  pp.  2(iO,  2(!1),  with  tho  result  that  i>aluf»r  wai> 
promptly  abandunod. 

It  is  important  to  bear  in  mind  that  thronirhout  tbewholc 
of  the  time  strong  Bubliinate  solution  (1  in  lODO)  was  used 
for  hands,  instruments,  &C-, nil d  measures  were  taken  to  pre- 
vent deterioration  of  the  solution.  Tht-'SB  incasurca  cull 
for  brief  mention  here  I  may  say  at  once  that,  as  ueithur 
permtiuguiinte  of  potaatiium  nor  silioo-SuoridQ  of  sodii.  nru 
incompatible  with  porchloride  of  mercury,  no  considorn- 
tioD  of  this  kind  need  detain  us. 

Ag^ain,  though  for  some  time  Coudy  irrigation  has  been 
employed  before  delivui-y,  no  important  deduction  on  this 
score  need  be  made,  for  any  dotorioratiou  of  iho  solution, 
which  may  have  rotiulted  from  admixture  with  the  small 
quantity  of  glycerine  used  in  preparing  tho  Rtock  solution 
and  for  lubrication,  has  beea  guarded  against  by  coa- 
tiuuiiig  the  douche  until  ib  returned  unaltered  iu  colour. 

Again,  as  regards  the  aiibliinate  solution,  evury  precau- 
tion has  been  observed  to  prevent  cuuLamiutition  with 
soap  (which  throws  down  the  [icrcbloridc  us  an  insoluble 
mercurial  soap),  or  with  bright  steel  or  copper  (which  seizes 
upon  the  metal  of  the  mercury  salt  and  deposits  it  in  the 
metallic  state) .  The  importance  oE  preventing  even  a  slight 
dogroo  of  coutaTiiinRtion  from  either  source  was  at  once 
rt-'CuguiHod.  Very  little  contamination  in  virtue  of  the 
atLunuated  strength  at  which  the  solution  itt  used  being 
safiioient  to  destroy  tbu  whole  of  the  subUiiiate,  every 
means  was  taken  to  guard  against  it. 

The  solution,  therefore,  has  been  exposed  to  no  con- 
siderable deterioration. 

When  fintb  employed,  however^  it  was  the  prncliou  to 


290 


rmrBB  in  cniLbniei). 


make  a  concuntrutcd  aqiiiHitiu  sulaUon  which  miglit  staud 
bj  for  weeks  btitoru  it  wus  all  used,  aud  thus  become  de- 
teriorated by  the  alkalino  coustituenls  of  the  water  which 
bIowIj  precipitate  the  mercury  in  the  form  of  calomel. 
But  even  thin  wtia  aiibsoquuntly  obviated  hy  preparinjj  the 
solation  for  use  directly  from  the  concentrated  solation  in 
glycerine  as  delivered  from  the  cheiciat,  am!  xince  the 
begiauiug  of  July,  1636,  by  the  additiou  of  a  small  quan- 
tity of  acid  (Acid.  Uydrochlor.  dil.  "iss  to  Hydrarg-. 
Perchlor.  gr.  j).  Whatever  the  amouut  of  deterioration 
fnitn  bhi»  sourci:  may  have  beou,  it  dous  not  toll  to  the 
detriment  uf  the  hospital  iu  the  latter  half  of  IStii,  during 
which  time  I  can  petBoually  vouch  fyr  the  frequent  occur- 
rence of  such  deterioration.  I  regret  that  1  am  unable 
to  trace  the  preciso  manner  iu  which  the  solution  was  pro- 
pared  during  the  first  half  of  1885,  and  therefore  cannot 
fiay  what  relatiou  il  may  have  borue  to  the  relapse  which 
then  occarred. 

Be  this  as  it  may,  the  important  fact  remains  that  for 
the  laal  five  years  neither  more  general  hygienic  measnros, 
nor  the  »oliition  employed  for  the  hands,  instruments,  Ac., 
nor  tht:  lubriuiiut,  have  Buffered  appreciable  variation.  On 
ihit;  accoaut  special  interest  atloohea  to  Kuch  advance  in 
tho  death-rato  and  in  the  fevor-rate,  and  to  euch  recur- 
rence of  septic  illness  as  is  associated  with  variation  in  the 
etrougth  uud  character  of  the  douche- solution.  The  solu- 
tion employed  for  wo-ahiag  the  external  genitals  has  bocn' 
invariably  tlio  same  as  the  douche.  Tho  bearing  of  this 
is  of  cousideratlG  moment,  aa  will  immediately  a])pear. 

Now,  apart  from,  tho  antieeptic  actiuu  imparted  to  it 
by  the  antlxeptic  agent,  there  are  two  wayH  in  which  tho 
douche  acts  beiieBcially,  of  which  the  first  is  ujechanical— 
a  more  flushing  out  uf  the  passages  aiding  the  removal 
of  detached  portions  of  tissue  and  of  blood-clot ;  the 
second,  ecbolic — tlie  tt-nipernturo  at  which  it  iti  given 
(115"  P.  immediately  after  delivery,  and  110°  in  the  lying- 
in  wards)  »tiutulating  the  utei-iue  muscle  to  action,  and 
thereby  preventing  the  forojation  and  assisting  the  expul* 


rZVKV.    IS    CHILDBED. 


291 


sioD  of  retained  products.  Thig,  however,  woald  take 
pUice  equally  whether  mere  sterilised  water,  or  aalufer,  or 
sublimate  solution  lie  employed. 

It  ia,  therefore,  reasonable  to  conclude — 

(1)  Tliat  as  DO  chaage  ha?  beea  made  in  the  method 
of  odmiQistoriDg  the  douche,  its  mechanic'ftl  and  echolic 
effects  hftve  reniained  unimpaired. 

(2)  That,  SB  the  strength  and  character  of  the  antiBeptie 
agent  employed  in  the  douche-solution  has  been  the  only 
variable  factor,  corresponding  varintions  in  the  condition 
of  the  hospital  afford  evidfmce  of  their  compai'ative  valne. 

I  shall  now  show  that  such  variationa  have  occurred. 

The  charts  show  tliree  relapses  in  the  septic  element — 
one  in  the  first  half  of  1885,  to  which  I  have  already  rC' 
fcrred,  a  :*econd  at  the  beginning  of  1>S87,  and  a  third  in 
tht'  auttimn  of  1888.  This  last,  which  appears  the  least 
important,  is  for  reasonR  which  I  shall  presently  explain 
the  most  8o.  Two  of  the  oases  of  septic  poisoning  proved 
rapidly  fatal  during  this  rclapsf,  and  on  that  account  the 
record  of  the  fpTor  was  cut  short  early.  A  aimihir  fatality 
took  place  in  the  antumn  of  I88-'>,  which  for  the  t^amu 
reaiion  loft  hut  little  truce  ou  tho  fever  chart. 

Now,  it  i«  a.  remarkable  fact  that  the  only  three  deaths 
from  septiciBinia  (kar  Fatal  Cases  10,  13,  14)  which  have 
occurred  during  the  last  five  year.s  should  have  taken  place 
in  the  two  nhort  intervals,  amounting  together  to  less  than 
twelve  weeks,  during  which  either  subllniate  sohitiun  of 
diminished  strength,  or  salufer  were  employed  with  the 
douche.  For,  oven  after  allowing  duo  prominence  to  the 
fact  that  in  one  of  the  cases  sublimate  alone  was  used, 
and  that  ^ev€ro  traumatic  influences  had  boon  brought  to 
bear  upon  it,  the  difference  in  the  death-rate  is  very  strik- 
iug.  It  is  obvionsly  an  unfair  to  include  this  case  in  ono 
category  as  in  the  other.  If  it  be  excluded,  two  deaths 
from  eeptic  poisoning  will  bo  found  to  have  occurred  in 
94  oases  douched  and  washed  with  weak  sublimate  and 
aalufor  nolntions,  agaiiuft  one  iu  2026  cases  iu  which  strong 
sublimate  solutions  were  used  ;  and,  if  it  be  included,  three 


fSV%R    IN    CBILDSED. 


doathB  wUI  be  seeo  to  have  taken  pince  from  Reptic  poison- 
ing among  114  o&bos  admittod  vhilo  the  weaker  doiioho- 
solutions  were  in  use,  against  no  uuch  death  in  2036 
admitted  when  the  stpoiiger  douche-solutions  proffailod. 

"With  regard  to  the  first  of  these  periods,  during  wliich 
the  Bublitnate  douche  of  diminish^ed  strength  waa  emplojred, 
the  eWdciice  of  the  relapse  reats  entirely  on  the  single 
death  from  septicaomia,  it  ia  iiot  supported  by  the  occur- 
rence of  other  Reptic  cases.  But  as  27  patients  only  were 
treated  in  the  same  way,  tliis  result  is  not  surpiising. 

The  second  period,  during  which  the  salufer  douche 
was  employed,  calls  for  more  extended  comment. 

I  have  carefully  analysed  the  cnses  adroitteii  from  the 
beginning  of  August  till  the  end  of  Octobei" — 136  in  all. 
Of  tlioae,  77  were  washed  and  douched  with  salufer;  10 
others  distributed  about  among  Lhem,  and  iu  which  from 
tlie  character  of  the  labour  there  was  special  reason  to 
fear  the  introdnctiou  of  septic  material,  were  duaoUed 
with  eubllmate  entirely. 

This  inveatigatiou  shows — ■ 

(1)  That  during  the  eight  weeks  of  salufer  doucliiug 
two  deaths  occurred  from  septic  poisoniug,  unH,  though 
severe  traumatic  iuflueuccs  had  been  brought  to  bear  in 
the  firdt,  no  snch  allowance  can  be  made  in  the  case  of 
the  second  which  followed  n  normal  labour. 

[i)  Tha,t  duriug  the  same  period  three  additional  cases 
of  septic  fever  occurred,  whereas  during  the  first  half  of 
August,  i.  e.  before  salufer  was  introduced,  and  during 
the  latter  half  of  October,  e.  e.  after  salufer  was  abolished, 
no  such  case  occurred. 

(3)  That  some  of  the  teiupcrature  charts  during  the 
salufer  period  were  beginning  to  revert  to  the  type  wit- 
nessed during  the  carbolic  and  Condy  era,  iiud  that  the 
longer  the  salufer  coutinued  in  ubo  the  more  frequent  aud 
more  striking  became  euch  iusitaucea. 

Tliese  facts  to  my  mind  are  of  distinct  siguifioance. 

That  this  retrogreasion  does  not  Gud  marked  oxpression 
in  the  foregoing  pyrexia  cbarttt  may  be  readily  accounted 


FITBK    IK    CHILDBED. 


298 


for,  when  it  is  remembered  tliat  salufer  was  einployetl  for 
ciglit  weeks  ouly,  and  was  commenced  iu  tlie  middle  of 
one  nod  disooutiuued  in  the  middle  of  anotlior  moutti,  with 
the  effect  that  the  unsatisfactory  salufer  caaea  arc  (whi;n 
the  general  fever-rate  and  septic  rule  are  cxprcesed  as  in 
tli6  chart  for  the  whole  of  each  month)  diluted  by  the 
satisfactory  sublimate  cases. 

■  Moreover,  in  eftimating  the  eoropar&tire  vftluo  of  tho 
Biilnfcr  and  .sublimate  douche,  the  fact  muet  not  bo  lost 
eight  of  that  in  those  cases  iu  which  septic  iufoctJou  was 
dreaded  suhliniato  was  alone  employed.  It  is  but  fair  to 
conclude  that  had  thlu  precautiun  been  omitted,  the  com- 
puriiion  would  have  been  still  inure  pronounced. 

7\ihle  IV  (p.  294.)  seta  furth  tho  eompurative  result  of 
the  BBlnfer  and  sublimate  douching  upon  the  ISl>  cases 
admitted  during  tho  three  mouths. 

ConipOrro  aUo  the  figures  given  in  Table  IV  with  thoso 
given  iu  tho  second  column  of  Table  11  (p.  203). 

This  shows — 

(1)  That  the  death-rate  rose,  and  from  septic  poisoning. 

(2)  That  tho  proportion  of  labours  followed  by  fever, 
and  especially  by  septic  fever,  increased. 

(3)  That,  in  the  febrile  cases,  both  thoaverugu  duration 
ajid  the  aversgu  height  of  the  fever  iucreaoed. 

[4}  That  both  the  ^ueral  fovcr-rate  and  septic  rate 
advanced. 

1  have  already  stated  that  it  was  in  the  antl»epbic  of 
the  douche* solution  only  that  any  tLlteratiuu  was  made 
Iu  virtue,  therefore,  of  this  result  it  is  probable  that,  had 
the  sublimate  not  only  of  the  doucho-solutiou  but  also  of 
that  employed  For  the  hands,  instrumentB,  &€.,  aud  uE 
the  lubricant  boon  replaced  by  sulufer,  and  had  saiufor 
been  used  iu  all  eases,  iusCi-ud  uf  in  those  only  in  which 
danger  was  leant  to  be  fearoJ,  the  effect  would  have  been 
still  more  disastrous.  _ 

It  is  concluded — 

That  liulurerisiuferiur  to  aubliuialc  as  an  antiseptic  agent. 

luuideuiully  evidence  bus  bet-n  ulTurded — 


2d4 


riVBB    IN   CHILDBBD. 


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PVTRR   IN    CHILDBED. 


295 


(1}  Of  tlio  yalue  of    doucho-solutions  ot  utroug  over 
Ihuse  of  weuk  autiseptic  power. 

(2)   Of  the  value  of  antiseptic  over  mere  aseptic  UoucLe* 
solutions. 

Kecogui(;iiig  the  mechauical  and  oobolio  advnnta^cs  of 
the  douche,  1  was  seriously  couaideriiig  the  ndvisabilitj 
iployiiig  water  merely  sterilised  by  boiliog — of  usiug 
aseptic  in  place  of  au  antiseptic  soliitiou — for  doucbiug" 
purpoHea  ilariDg  putrpery.  But  lu  virtue  of  thu  rBsult 
now  obtained' — whicli  I  was  very  far  from  auticijiating — 
of  umployiug  suUibioDs  of  dimiiusKed  Eintiseptic  power, 
ftuch  an  experiment  docs  uob  aecm  justiliablo.  Kor  if 
solutions  of  diminished  antiseptic  power  prove  inferior, 
stiLl  luvre  would  Boltitions  of  no  antiseptic  power  (merely 
aseptic)  nhow  to  disadvantage. 

And,  considering  tlie  results  which  have  bi>cii  obtninod 
when  tho  douclio  as  a  runtinc  uieaaurc  hatt  boon  discarded 
altogether,  I  am  forced  to  this  conclusion — 

That,  unless  the  solution  used  be  not  only  aaoptic,  but 
at  the  game  time  aiiliseptic  and  strongly  so,  thej  rouline 
employment  of  the  douclio  duriug  piierpery  is  liable  to  be 
attended  willt  positive  danger  to  the  putient,  and  that 
under  .inch  circum stances  its  mechanical  and  uchulic  advan- 
tages uiay  be  more  than  counterbalanced  by  its  want  of 
sepsis-dcfitroyiug  power. 

I  am  of  opinion  that  this  may  bo  explained  by  the  fact 
that  in  the  introduction  of  the  pipe,  even  whon  an  al'tempt 
is  made  to  cleanse  tho  parts  boforohundj  septic  matter  is 
Gtill  apt  to  lurk  about  perineal  lacomlionB  and  tears  of 
the  vulva,  and  may  be  carried  by  this  mtmus  from  th« 
lower  part  of  the  vaginal  strait  to  the  upper  [)art  of  the 
parturient  canal,  where,  escaping  immediate  det<tmction, 
it  ia  liable  tu  become  absorbed. i* 

I  wonld,  therefore,  nrgfr— 

(1)  That  such  an  antiseptic  solution  should  be  used  oa 

is   capable   of  effectually    and    rapidly   destroying   septic 

*  1  haw  alTMdji  Kltmiii  by  vxpvriiHuut  thiit  (oluliuiiK  iatiudiuwil  iiito  Uic 
v»giii>  sia]  rMch  ik*  utcriue  a«ilj.  'Obatrl.  Tna*./  vol.  ttt,  1888,  p.  806. 


296 


KHVEK    I'S    CHILDBED. 


muterial,  and  that  tlio  exteraul  gc-iiitals  tidoiild  bo 
fully  washed  beforehand  with  a  similar  sulutiou. 

{'i)  That,  failing  this,  the;  doucho  as  a  routitio  moabure 
had  far  better  l»e  discarded  daring  puerpery. 

It  will  be  obseiTed  that  these  remnrks  apply  solely  to 
^(ter^itri/,  and  to  the  rtiuUne  utte  of  the  douche.  I  would  on 
no  account  omit  the  routine  use  of  the  duucho  during 
lahattr,  nor  counsel  its  nt-gloct  iu  Cfirtmn  caaee  uftcrwards, 
even  when  the  above  precautions  are  not  carried  out  ;  but 
1  would  strongly  advise  that,  whether  given  as  a  routine 
nicasure  or  not,  it  should  be  used  attd  used  only  in  accord- 
nnce  vrit'k  ancli  precaiitions- 

It  may  be  urged  agniust  the  routiuc  use  of  tlie  doacho 
during  puerptiy  that  no  ueceBsity  for  it  exists  in  tlio 
uiajorily  of  lying-in  ca-ws.  To  this,  I  aaswer,  Eveu  so,  it 
is  the  minority  of  such  ciii^es  which  benefit  by  the  uieaaure 
applied  alike  to  the  whole  ;  and  it  is  thii  diRiculty  of  de- 
ciding beforehand  which  cases  will  fall  into  one  category 
aud  which  into  the  otlier  that  preveuts  it  from  being 
applied  8o!oIy  to  the  minority, 

I  have  Kbowii  th»t  tbi»  minority  proved  &n  undetermia- 
able  factor  during  the  ealufer  period;  and  aoit  must  always 
happen  while  patients  are  beset  with  50  many  possiblo 
Bources  of  infection  as  exist  in  a  lying-in  hospital.  Only 
wbou  these  sources  of  infeetion  can  be  removed  is  it  snfe  to 
UiHpense  with  tbo  contiuuaiico  uf  the  douche. 

I  haw  produced  Huflicient  evidence  to  ehow  that  eveo 
with  the  routine  use  of   strong  subEimate  solutions  thb 

DANGKK  SriLL  LIES  LKSS   IN   MKRCURIALI8M  I'AAH   IN  SKKSIII, 

Therefore  I  cont^Uide — 

Thatj  unless  and  nntil  the  maaifold  eourcea  of  septic 
iiifcutiou  can  he  traced  aud  with  certainty  dealt  with  nut- 
Kidu  the  budy,  ihu  rouLiu»  empEoyuivnt  of  the  doucha. 
needs  no  defonco. 

Reverting  now  to  the  douche-solutions  of  the  carbolic 
and  Condy  era,  it  may  be   remarked  that  a  like  criticistn^ 
applies  to  the  Coody  douche  which  was  used  during  puer- 
pury  as  to  the  sulufer.     The  Hiiiglu  carbolie  solution  which 


RTIR    Dt    OBILOBBD. 


29: 


was  used  immedifitely  nfter  labour,  b^ing,  so  to  tupoak,  a 
concentrated  Bolutioii,  Buffered  Irtlle  dctcriofation  in  com- 
parison i\'ith  tlie  uiTicli  more  attenuated  pennatigunato 
solution  wliicli  was  used  for  tlie  doiiclie  daring  |iuerpery. 
This,  for  reasons  which  I  have  alrt-ady  given,  was  more 
oftoii  than  not  reduced  to  at  best  a  very  we»k  antiseptic, 
or  to  a  merely  aseptic,  solution. 

Finally,  there  ia  one  further  consideration  which  calls  for 
mention  in  estimating  tlie  comparative  value  of  aiiti&cptic 
agents.  1  refer  to  the  direct  local  effect  of  these  agents 
00  the  tissues  of  the  body.  With  regard  to  the  carbolic 
douche  employed  immediately  after  labour  duriug  the 
cnrbolic  and  Condy  era,  it  may  be  urged  that,  entirely 
apart  from  their  comparative  antis«'ptic  value,  the  carbolic, 
being  far  more  irritating  when  locally  applied,  was  more 
liable  thnn  the  sublimate  to  alfect  injuriously  tissueH  which 
were  already  in  a  more  or  less  damaged  condition,  and 
to  this  fact  may  be  attributed  iu  womc  mt'aaure  tho  Hupe- 
rior  results  obtained  when  tho  former  was  replaced  by 
tho  latter.  To  what  extent  Ihia  may  have  affected  the 
result  it  is  impossible  to  say.  No  aucU  coue^iderntinn, 
however,  attaches  to  ihechnrgOB  which  were  subsoqueutly 
made  in  the  douchc-soIutiouB,  for  neither  permangimato, 
nor  weakened  sublimate,  uor  »ialufer  ai-e  us  directly  irrita- 
tion to  the  tisHuea  nti  either  the  carbolic  or  the  strong  Bub- 
limato  Boliitions.  This  conBiJeratinn,  therHfore,  dooa  not 
nffeel  the  value  of  the  evidence  which  I  have  adduced  in 
support  of  the  inferiority  of  weak  sublimate  and  of  Halufer 
douche-sol  utions . 

General  Stimmary  tif  Part  I, 

(1)  By  a  study  of  the  f-cni-^ral  f«v«r-ratr,  of  the  septic  rate 
and  death-rato.  aLd  by  au  aualysis  of  the  iiiori'  severe  caaes  of 
illoeaa.  tlio  state  of  Uie  hospital  liaiibi-oa  determined,  and  varia- 
tions in  itJi  condition  hav*?  been  pwiiitoil  out. 

(2)  The  servicv  of  the  hosiiital  and  the  cbangos  (both  of  a 
goncral  hygienic  imturv  itnd  iiIko  Huch  us  pertain  more  (inrticu. 
larly  to  autisepti««)  which  wore  cfTectod,  haw  bevu  drscribe<l. 


296 


rXVEH    IM    CaiLDBKD. 


(3)  Tbc  coincidence  of  tbesp  cbanpoa  with  Tariations  in  fbe 
oouditioD  of  the  lio»(jiUl  biut  b«c*u  truixit]. 

(4)  npou  these  dnti  it  is  uoacluded  that  tx.  gradual  improve- 
ment romiltc^d,  {inrtlj'  fr^m  ^jstcniatiG  nttoiuiou  to  poiiita  of 
general  Kygifne,  ami  jiarllv  from  jtractire  in  dfatiii^  with  the 
ontiacptica  used;  and  that  fi  furthcir  improvement  wnaeffect«l  hjr 
the  eiibstitutioii  of  kubUmatc  for  carbolic  n^'id  aud  Condy's 
fluid  as  the  gpueral  aotisuptic  in  usf,  but  that  retrojfrMaion 
nocurrt^d  both  wbtu  tbt;  suhliitinto  tloucho-solutioii  was  r^uoed 
ill  atn^n^th,  and  a^ain  when  the  sublimate  of  the  doticlie- solu- 
tion wa8  rcjdaccd  In-  wihifur 

(5)  In  virtot-  of  this  result  it  ia  contended  that  as  an  anti- 
septie  Hytmt  suhlimHtc  18  supvrtor  to  carbolic  acid  luid  Condy'g 
and  also  to  Halufer. 

(6)  Pinally.  thut  aa  the  antiBcptiu  of  tho  douche-sohition  was 
the  oulv  element  whieh  Biilfered  variulion,  the  value  of  strong 
doticho-BolattouB  compared  with  douclie-aohitions  of  weak  anti- 
»c]iti<!  jMiwor,  and,  aforlinri,  the  viUito  of  antiaitptic  compared 
with  mor^  UKuptic  duuche-Holutioiiii  is  rendered  obvioua. 


Dr.  Braxton  Qickb  said  that  it  was  by  giich  pauers  as  ihia 
that  wf-  should  soraf>  dny  arrive  at  th.*  ftolulion  of  tee  cause  of 
puerperal  troiibli-s.  ll  was  a  queatjou  which  nutumll/  intere«t<.-d 
biin  tniieb.  for  at  the  Duhliu  uieeliug  of  tlip  British  Association 
many  yeara  a^o  he  had  read  a  paper  "  On  the  Uso  of  AutiDcplic 
[Jturiue  lujeetioiis  after  Labour  with  Offensive  DiachareeB,  as  n 
Ruly  of  Prtiiitici',"  On  tbat  oti^nioii  he  wiis  fiatouisheu  to  find 
this  ruleupposod  bv  the  laUt  Sir  JumeH  Simpaon,  who  viewed  with 
Aiixioty  such  trofltmont ;  tvt  that  time  Dr.  Hicka  rejoined  that  he 
would  rather  have  rlean  water  thiui  *itiultiiig  disdiarj^L's.  Ho 
was  therefore  ninoh  gratified  hy  the  resiiltH  hLowu  in  the  paper. 
But  be  tbouRhl  earo  wan  necessary  in  using  the  injections;  and 
also  he  alluded  to  iiuotber  risk,  aamely,  the  effect  of  much 
Miovement  of  the  patient,  whieh  wiw  liable  to  load  to  cxjjanBion 
of  the  thorax,  and  thus  to  "  insuck,"  whereby  irritating  material 
could  he  drawn  iu  tbroiigli  any  openiiifjr  iu  VL-innor  lytnph-spacoK, 
tiB  Dr.  Hicks  had  pointed  out  iu  ;i,  paper  before  the  Misdical 
Society  and  tii  the  'American  Journal  of  Medical  Scionees.' 

Dr.  Ha,yeb  reL'retted  thai  Dr.  BoxiJI  hud  nut  included  in  hi« 
r^ipurt  tb<^  period  when  he  mid  Dr.  Fancunrt  Barue»  were  phj- 
eicians  at  tlitf  bospilal.  Thev  took  up  the  work  in  Septen^her,  1879, 
aft«r  the  complete  ruorganiaation  of  the  hoapital.  which  he  luid 


mVER    IN    CHILDBED. 


299 


tblargc  sbftrc  in  bringiu^  about.  PrcviouB  to  the  ri^or^auiiiatioii 
b«  bail  !Ltt«Dipti>d  to  ititnidiiCH  name  oiitiseplic  tui^asureB,  but 
tber  had  been  streououalv  op])aHed  by  tbe  authorities  and  some 
u(  ah  collea-guos.  lu  lyVtf,  uiiou  tbe  niO|»eiiiiig  of  Ibe  bosfiital 
uudcr  an  tulimlv  uew  s^MtJi-iii,  tlif  HTjtlKfiJt.it;  rtiJi-s  otlojityd  were 
tbose  drawn  »p  by  Sir  Josei>h  Lister.  Absolute  pbeiiol  waa  the 
autiaeptic  asod — 1  in  20  for  bands  and  iafitnimeiita.  and  I  in  40 
lor  vaginal  injections.  Their  results  were  highly  satisfaptorv. 
Ho  hiid  had  only  oiic  case  of  Rerious  illness,  and  that  vait  nn 
inntauiM:  i>f  supticiBuiiu  iiiducL*d  hy  niiqiio6tii.>uablL-  disve^rd  of 
tbe  antisHptic  rules.  Tbe  jjatient.  however,  recovered.  Dr. 
Httve.i  had  adopt+^d  vaginal  injeclions  with  1  in  40,  or  1  in  HO 
cNirbatic  acid  in  every  case  for  tbe  first  week  after  labour.  J>r. 
Barut^'M  used  no  viigiiial  iiijt!ction»,iLnd  Uh  cnaes  dtdeqiialK'  wl-II. 
Hu  was  ntnink  wjtli  this  at  tlu"  tinie.  He  now  tUoii^dil  tbitt 
vagiual  douching  after  labour  as  a  general  rulewiw  unDt-cessarv- 
^indeed,  wilh  the  onlinary  run  of  nuTMw  it  was  dan;efiToii.«  Sunn 
nurses  were  earelesK  about  the  cleanlmeHs  of  the  tulies,  &e.  Ho 
had  therefore  given  it  up,  unless  the  lochia  became  offensive,  or 
tho  pftlii;nt  elbowed  Kymj^uuiH  vi  illness.  In  auituble  coses  he 
strongly  advocated  intra* uterine  injectiong.  but  to  he  of  value 
they  flhould  be  eopiouB,  and  the  whole  iutenor  of  uterus  fre>>iy 
bathed.  For  this  [mr|)otie  hie  own  tube,  giving  (orfcli  a  is|iray, 
wan  very  iiatisfitctory.  He  bad  quite  discarded  nil  diaperx,  and 
used  now  antiseptic  absorbent  wool,  such  ae  that  impregnated 
with  ft&licytic  acid  or  sal  aleinbrath.  During  labour  all  va^nal 
exaiiiiuationtt  ebould  be  made  with  abeolutfly  cle&n  h&udit  and 
earbolined  glycerine  (1  in  15). 

Dr.  Leith  Napieb  cougriitukted  Dr.  Boxall  on  bia  elaborate 
statistical  record.  He  tbounht  that  oompamtirely  few  men 
vould  have  undertnLen  Hueh  hLlmrious  inquiry  with  so  Hiiiall  a 
prospect  of  practical  result.  But  Dr.  Boxall  had  attuiued  prac- 
tical resulta.  Ho  hitd  shown  that,  ut  leaBt  bo  fur  as  lying-in 
hospitalu  were  coUL-eniod,  iiiorbidity  wus  greatly  le&tiuned  by  the 
routine  UM  of  mtrctirial  douching.  Previous  Biwakers,  especi- 
ally Dr.  Hayes,  bod  auticijHbted  mauy  points  about  which  Dr. 
Napier  held  strong  couvictiouji.  Tbere  might  be  geuural  agree. 
m«nt  ibat  routine  douching  wau  n«)e«Hsary  or  at  least  advisable 
in  lyiug-iu  hospitaU  whero  large  numbers  of  puerperal  women 
were  aggregated,  but  he  tnurh  que«iioned  if  the  same  iii«uun>ii 
were  required  in  privftt«  ]>r«*?tiee.  He  (iskwl  ©r.  Boxall  if  he 
believed  that  mercurial  duucbiug  wae  an  absolute  preventive 
of  neptictemia.  If  there  was  no  abnormal  &igu, did  not  Dr.  BoxitlL 
admit  that  the-  poraiblo  and  undispntLHi  risks  of  douohing, 
es)>ociaIly  if  Hyrinffvs  were  used,  were  greater  Ihuu  the  nak  of 
waiting  till  indii^tiona  firoBo-'  Tbe  ratio  of  possible  miHcbief 
fironi  H  general  employment  ot  mereurials  in  non-septie  inuiea 
must  not  be  oTcrlook«d.     Fur  several  yean  Dr.  Leith  Ifupier 


soo 


yKVNB    IN    CHlLDBtD. 


hiul  8_rstfiiiiiticiilly  ordered  douching,  but  ho  had  for  ROme  con- 

Bick'raltle  tiniu  abcindoned  the  [)nu!tict<!  ualeaa  iucreaaed  tempcra- 
tur«  uud  j>uUt'  or  local  aigiia  of  toxteniia  iitoae.  lu  iiiilntnuutoiTJ 
jdiei'jjenti  i;ii.-sc?t  Ert-quent  dutiililti^  wtiH  Imrtriil ;  riLgiuiLl  supposi- 
tork'aof  ioJofurm  WL're]iryfurabk>.  Merfurio  [wrohloride  was.oQ 
the  wliolc,  the  best  antiseptic  for  the  purpoau  at  preaeot,  tut  it 
bad  nian/  objectioos.  OE  late  lie  iiiwJ  u»ed  freoline,  which 
seemed  to  aaswer  well ;  it  bad  the  advaotagc  of  beiue  non- 
poisonous.  He  trusted  that  Dr.  Boxall  would  eoutinue  biaworb 
ret^iLfding  the  miTitB  of  ihu  rarioua  antisoptic  a^ntu,  and  that 
eventually  some  other  and  better  drug  would  be  found  to  roplnov 
the  pei'c  bio  ride. 

Dr.  Walteie  Okiffith  uiid  that  tUo  [juiistion  which  would 
interest  the  yreat  bulk  of  practitioners  of  midwifery'  waa.  How  far 
were  ihene  preeautions,  which  had  been  proved  beyond  poMi- 
biJity  of  doubt  to  be  ueccweary  to  reiidc-r  aaic  the  iionSticuifutii 
oE  women  oollt^ted  together  in  lyiug-iii  wards  and  L>ospit:ils,  to 
be  adopted  in  tbo  ca»L<  of  liidividuala  uoulined  separately  id  their 
own  houses  ?  It  was  obvious  that  the  riak  was  greater  in  lite 
Eoriupr,  but  that  the  difference  was  uot  due  lo  a  differeuti?  in 
kind  80  uiucL  as  in  degree.  It  would  lio  invaluable,  but  a  very 
difficult  mattor,  to  oLitain  such  tables  as  those  compiled  by  l>r. 
Uoxall  of  the  latter  class  of  cases  in  unmbers  suBieioiit  for  oom- 
[mriijoii.  If  the  hauds  of  the  attendant  nnd  Qiir«e,  all  tbo  in- 
Htruuients  and  appliaticcH,  fttid  the  patient  herself,  were  kept 
clean,  aJl  routine  douching  could  be  done  away  with  On  the 
other  hand,  most  people  aeeustoiued  to  habits  of  cleaiilineas  pro- 
teiTcd  II  douche  ol  some  kind  nij,'htftud  moraiug  for  the  first  few 
(laVH  afLi'r  lubour. 

Dr.  C01J.1NOWOKTH,  as  a  member  of  the  present  staff  of 
visiting  physicians  at  the  Qenoral  Lying-in  Hospital,  oxprc8»e<l 
hie  j^ralefii]  tipprecifttion  of  Ihe  valuable  paper  to  which  they 
had  lisleued.  He  (Dr.  Cuiliugworlb)  came  on  the  s<*ne  at  a 
timy  when  the  victory  over  puerponil  inteclion  in  that  bcnpital 
was  already  uearly  cotuiilete.  He  could  therefore  take  no  cnxlit 
to  himself  for  the  eicellence  of  its  preseut  condition.  Iiideed,  a 
fllightfy  retrograde  movement  had  followed  Uia  appointment, 
for,  in  his  desire  to  find  an  antiseptic  which  ahould  be  ft»  efficient 
as  corrosipo  sublimate  aud  yet  noii-poiHonous,  lie  had  thought  it 
his  duty  1«  iiitroduee  ealufev  at  the  liobptttil  iui  a  eubiitituto  for 
corrosive  aulitliualo  in  douching.  Salufev  had  been  most  highly 
spoken  of  by  a  well-known  professioikal  cheniisi,  who  had  tnadd 
a,  series  of  ciperiiiieuts  to  determine  its  value  as  an  autJseptie, 
and  had  L(*n  reported  by  Mr.  Mayo  liobson,  of  Leeds,  to  answer 
well  iu  ordinary  surgical  practice.  Notwithstanding  this  double 
recommendation,  they  began  to  go  a  little  wrnng  fjom  the  time 
of  ila  introduction,  aud  at  the  cud  of  two  luouthii  bo  did  not 
feel  justified  in  continuing  its  use  any  longer.     He  therofori}  r«- 


I 


I 

I 


7EVEB  IK  CBILDBBD. 


801 


turned  to  the  sublimate  doucting,  with  the  result  that  the 
patients  at  once  began  to  recover  (uore  aatisractorJly.  He  looked 
foward  to  &  time  when,  witlj  increased  knowledge  of  the  means 
of  combatiugsejrtic  infectiun.douirbing  could  he  Bafely  aboliKbed. 
At  present,  however,  in  hospital  practice  it  Beemed  essential. 
Id  pritate  practice  he  did  not  thicK  it  was  bo  netfBsary.  AJid, 
even  as  regards  hospital  practice,  it  must  not  \ye  forgotten  that 
inthelyiDg-iDhoBjiitalBof  Bostoiiand  New  York,  the  best  results 
were  liot  oht&ined  udUI  the  douche  was  dclibemtcl;  abandoned. 
Revcrtiiig  once  again  to  the  disaitpuinling  resultg  of  the  use  of 
ualufer,  h(\  might  say  that  a  pOHsible  cause  of  failure  woe  the 
clogf^iD^  of  tlio  vnlrea  and  apertures  o£  the  appai-atus  hy  the 
salufer,  which  was  tJirown  down  from  the  solution  in  I'onsid emhlc 
quantity.  In  reference  to  the  use  of  an  absorbent  subsUtuti;  for 
the  ordinary  diaper,  ho  could  apeak  most  highly  of  wood-wool 
pads.  They  were  euperior,  lu  his  experience,  to  pads  of 
aliBorhent  wool,  and  were  now  regularly  used  at  tie  General 
Lying'in  Hospital. 

Dr.  BoxALL.  IB  reply,  thanked  tliu  Societr  for  the  uttcntJon 
which  bad  lieeu  given  to  his  paper.  He  would  address  himself 
briefly  to  the  many  iuipartauL  points  raised  by  the  several 
epeakers  in  the  di&cuasioa.  He  mi^^bt  add  to  his  remarks  that 
the  intra-uteriuc  douche  was  rcaervcd  for  cofies  in  which  th« 
hand  or  eoine  iostrument  had  been  introduced  into  the  uterus, 
01'  in  which  the  foetus  wa»  maoeratcd  or  decomposed,  or,  agaiu, 
in  which  clots  or  pieces  of  membrane  were  retained.  In  such 
caKS  it  was  his  invariable  practice  to  employ  it,  both  in  hospitaJ 
Md  in  private,  iramediateiy  after  hibour.  But  during  pucrpery 
he  introduced  the  tube  intu  the  utorue  only  in  exceptional  cases, 
and  in  these  be  usually  employed  a  soft  rubb4>r  catheter  or  piece 
of  elastic  tubing.  He  felt  confident  that  much  harm  of  one 
kind  or  another  might  be  producod  by  the  indiscriniiuatc  use  of 
the  uteriue  tube  wliciiever  the  lochia  tiecanie  offensive.  For, 
though  these  conditions  were  oflori  aasoeialed,  on  the  oue  baud, 
offeQsivenesa  of  the  lochia  did  not  neccsiarUy  iiidicate  Geptic  de- 
composition, while,  on  the  other,  septic  dccomposilion  might  tak« 
plact)  without  it.  If,  however,  there  was  good  reason  to  susp+'Ct 
the  occurrence  of  Bcptic  dccompoiition  in  the  parturient  tract,  ho 
would  proceed  seriatim  and  i-xuniiDc  first  the  part«  about  the 
vulva  and  lower  vaginal  strait  (for  it  is  in  that  situation  that 
decomposition  most  frequently  occurred),  cleanse  and  wash 
them  thoroughly  with  strong  antiseptic  solution.  If  that  Failed 
to  reach  the  root  of  tho  mischief,  bo  would  next  douche  the 
TOgina;  and  only  after  this  had  l>ecn  done  would  he  resort  to 
iutiiL-utenue  douching.  In  this  nutnncr  tho  risk,  which  he 
felt  was  very  real,  of  carn-ing  septic  mutter  from  the  vulva  or 
va^inib  into  the  uterine  cavity,  and  thereby  increaaing  the  mis- 
chief,  might  be  obviated,  or  at  any  rate  dimiiiishcd.     Whether 

VOL.  XX5I).  21 


aoa 


FBTEK    IN    CaaDBED. 


the  iitcrini}  ttibo  he  uecd  or  not,  b«  voulcl,  vlicn  be  hud  rooBon 
to  ausptxt  ihnt  dccoin  posit  ion  had  takeu  place,  use  a  stroi^ 
Bolutiou  (percUloride  of  inenrurv  i  in  lOOO),  aud  pleotjr  of  it. 
He  considered  that,  in  such  a  oase,  it  wua  preferable  to  bring 
the  full  forcv  or  the  nutiHfptit:  ut  ouot;  iutt^i  play  to  running 
the  risk  of  baTing  to  repeat  tlif  prucetta.  Wheii  th«  paper 
was  written,  I>r.  Boxall  was  not  itwuiv  thiit  for  u.  time  iLft«r 
the  re-opening  of  the  hospital  iit  1870  carbolic  acid,  and 
carboli<;  aL-id  alonr.  was  used,  and  that  the  vagiaal  dourbe 
was  only  occasionallv  resorted  to  during  pu^rjierj.  Hut  tbis 
fact  is  importtkitt  in  ni-tue  oE  the  etnteumnt  of  Dr.  Ua^cs  that 
during  tbiu  time  there  was  less  illness  than  dnring  Iho  aubsv* 
quent  carbolii'  and  Condy  vm,  when  tlie  douebe  wus  <>mploy<xl  as  a 
routine  measiire  duriug  puerpery.  This,  however,  wts  preciwlj 
what  Dr.  Boxall  would  hare  anticipu,t«d ,  It  bore  out  the  con* 
tention  eipreased  in  the  paper,  that  the  Oondj  douche  utied 
duriug  puerpery,  owing  ju  great  i>art  to  tho  rcdoctioa  of  the 
pemianyBnute  by  carboli<.-  acid,  possv&scd  at  bust  hut  weak  aoti- 
septii-  power,  and  that  under  HUeb  conditions  more  harm  than 
good  resulted  from  its  routine  employment.  In  private  pructico 
Dr.  Boxall  invanaUty  ci»)>!oyed  lor  tb«  bauds,  &c.,  subLinutv 
solution  1  iu  1000  (wbteh  be  found  far  less  irritating  tlmn  car- 
bolic acid  Hululion  1  iu  20),  iLud  •!  sublituate  douobe  I  in  2t)0O 
during  labour  aud  immediately  after  delivery — reserving  tbe 
intra-uterine  douche  for  such  eases  ».» thoee  indicated  above,  and 
giving  as  a  rule  no  douehe  whatever  during  paerjjery.  He 
lookod  forward  to  the  time  when  the  use  of  the  douche  could  b0 
similarly  restricted  iu  hospital  practice ;  hut  it  was  eo  difBcult  to 
foresee  the  dangers  to  whitrh  individual  patients  were  inhject«(l, 
pacticulttTly  when  ministered  to  by  unskilled  midwives  ajid 
Dursea,  that  he  could  not  at  present  advise  its  omission.  Some 
such  selection  vaa  attempted  duriug  the  salufer  period,  but  it 
was  found  impmcticable.  It  waa  the  rule  at  one  time  to  iusctt 
an  iodoform  suppository  into  the  ut«rus  iu  all  ciLses  iu  which 
intru-nterine  irrigatii>n  had  been  reaortcd  ta^-uot  as  a  substitute 
for,  but  as  au  acu>ssury  to  tbe  douche.  As  far  as;  can  b« 
gathered  from  the  ti^iuperature  charts,  uo  advantage  waa  gained 
by  using  tbem  in  this  wtiy.  Dr.  Boxall  wa-s  not  diapused  to  look 
upon  tko  intruductiuu  into  the  uturuu  of  ua  iodoform  lx>ugie  as 
an  efficient  substitute-  for  the  iatra-uterine  douche.  The  pre- 
oautious  which  he  advocated  in  the  use  of  sublimate  vere  iodi- 
OHted  in  his  pa]iGr  on  mereuriallsm.  At  Icftst  as  far  back  as 
1882,  absorbent  pads  of  cottou  or  of  wood-wool  had  been  used 
in  place  of  nupkins  for  hoHpital  cases,  and  in  private  Dr.  Boxall 
invariably  recommended  absorbent  cotton.  This  pad  wis  burnt 
aft'er  use;  it  cost  no  more  than  the  washing  of  n  napknn,  and 
afforded  greater  comfort  t«  the  patient.  Some  yeara  ago  Dr. 
Boxall  made,  at  the  suggt^stion  of  I)r.  Cbampneys,  an  inrestiga< 


rKVER    nr    CniLDBED. 


303 


t!i>u  Into  the  compiLralive  [lower  uf  iibsorj>ti«ii  |)UitKi-8»i.'<l  hj 
wwxl-wool  auilvottuii.  Hi-  found  that  both  for  whIlt  au*l  for 
blood  the  sample  of  wood-wooL  wia  ioferior  iu  this  respect  to 
cottuii.  The  faculty-  for  abaorptiou  (inssessed  hy  ditferont 
samjiL^s  of  absorlient  ijottou  varied  very  oouBiderably,  ami  it 
waj  qiiiti!  possible  tliiLt  tbe  wood-wool  wlikb  wtia  uuw  iiiiinti- 
i'iKH.urL'd  wiis  aupunur  to  tbut  wliicli  wna  Srsl  put  ink)  tLo 
market.  LuBtly,  witli  regard  to  the  utrwogtli  of  the  aubliniu.te 
solution  ueceaaary  to  cope  with  sepsie.  Dr.  Buxall  uonaidcwd  a 
aolutioaof  1  in  lOOO  sufltuieiit  auduion:  tlia.D  suQicttiil  to  destroy 
aiiy  septic  iiiaterial  willi  wbich  it  cam«  iuto  cuiituet.  Hv  ttlso 
Lwliervd  that  tiuLittioiis  of  less  xtriiiigtb  won-  sullicitmt  in  many 
CIUC8,  b«cn.ui»e,  iu  addition  to  the  eepsia- destroying  jwwcr  of  the 
solution,  a  very  potoat  power  of  the  same  kind  was  possedsfd 
by  Iho  tiflsues  of  the  body;  and,  where  it  was  a  qneiilioii  of 
attacking  aeptic  matf-rial  in  the  paasagcn,  thint  iniiiit  be  taken 
iuto  aecouDt.  It  was  in  tliose  cases  only  iii  which  the  tissncb 
(either  IocbHv  or  as  the  result  taav  be  of  trauuiutiiim,  ur  getie* 
rally  where  nial-nutrition  prevailed)  had  lost  the  power  of  ronist- 
aiice,  aud  had  gone  over,  as  it  were,  to  the  side  of  the  enemy,  that 
the  whole  stri'ss  of  preventing  sepsis  wa.»  thrown  upon  iho 
uutiaeptie  luHiHuri's.  This  diffleiiUy  in  jL^imj^in^  the  remitting 
power  of  the  tiseues,  added  to  that  of  determining  tlio  rieliH  of 
infection,  in  individual  caacH,  entailed  tho  neceiwity  of  neiug^ 
BtroD>f  «olution«  iu  all  ea»e»  iu  order  to  prevent  itepsiK  in  a  eer- 
tain  proportion.  On  this  qu^stiou.  however,  Dr.  i3usall  spoke 
with  »uine  diffidence  at  the  present  motnent.  an  lila  intention  waft 
to  nay  iiioro  on  the  Rama  suliject  in  a  Ruboequeiit  piirt  of  thi> 
|>aper  oa  which  he  wu  etUl  engaged. 


II 


OCTOBER  2md,  1890. 

Alfbed  L.  Qa-Ubiit,  M.D.J  President,  in  the  Chair. 

ProBBDt— 44>  Fellows  and  4  YUitorg, 

Books  were  presented  by  Dr.  Carbouelli,  Dr.  Currier, 
Dr.  Pinzaui.aud  the  Council  of  University  College,  London. 

William  John  Gow,  M.D.Lond  ;  Alfred  A.  Kanthack, 
F.R.C.S.,  and  A.  Ajlmer  Orr,  M.A.,  M.B-Oion.,  were 
udmitted  Fellows  o£  the  Society. 

The  following  gentlemen  were  elected  Fellows : — 
Richard  Ackerley,  M.B.,  B.S.Oson.  (Ashburton)  ;  Arthur 
Norman,  Boycott,  L.R.C.P.Lonil.  {Hugeley]  ;  AVitliam 
Ueory  Laurence  Coupl«ud,  M.B.Caatab;  Charles  David 
Green,  M.D.Loud.,  U.S.  (Upper  Edmonton]  ;  Darid 
Berry  Hart,  M.D.Edin.  (Edinbui^h)  ;  Harold  Low, 
M.B.Cnntnb.(Sytienham);  Harrj'  Burgess  OBburn,  L.B.C.P. 
(Claplmm)  ;  A.  W.  Mayo  Rotsou,  F.K.C.S.  (Leeds)  ; 
John  William  Taylor,  F.E.C.S.  (Birmingham)  ;  Walter 
Tyrrell,  L.R.O.P.Load. ;  Samuel  W.  Wheatou,  M.D.Lond. 
(Clapham);  and  Edwin  Francis  White,  P'.R.C.S.  (Putney). 

The  following  gentlemen  were  proposed  for  election  : — 
John  Dysart  McCaw,  F.R.C.S.  (Kfist  Finchloy)  ;  Hugh 
Jones  Roberts,  M.R.CS.  (Penygroes)  ;  and  Henry 
Bartlett  Shillingford,  L.S.A.  (Pockham  Rye). 


VOL,  XXXII. 


22 


8oe 


THE  DEATH  OP  DR.   J.   MATTUEWS  DUNCAN. 

A  VOTE  of  oondoleace  on  the  deatb  of  Dr.  J.  Matthews 
Duncau,  past  Fi'oaident  of  the  Sovietyj  vras  put  from  tbe 
Chair,  in  the  following  form  : 

"  The  President,  Council,  and  Fellows  of  the  Obste- 
trical Socipty  of  London  take  the  earliest  oppor- 
tunity of  offering  to  Mrs.  Matthews  Danoan 
and  family  the  expression  of  their  deep  sympathy 
in  the  great  loss  they  and  tbe  profession  had 
BQStained  in  the  recent  lamented  death  of 
their  highly  distinguished  Honorary  Fellow, 
Dr,  Matthews  Duncan." 

This  vote  was  carried  ananimoualy. 


KIGHT    OVARY 


AND   TUBE 
BLOOD. 


DISTENDED  VHTH 


By  William  Duncan,  M.D. 


UTERINE  APPENDAGES  THE  SUBJECT  OP 
TUBERCULAK  DEPOSITS. 

By  WaiiAii  DiTNOAM,  M.D. 


UTERUS  WITH  PRIMARY  CANCER  OF  THE  BODY 
EXTIRPATED  PMB  VAGINAM. 

By  WlUUM  DUHCIH,  M.D. 


807 


DELBASTAILLE'S  SPECTJLUM  A  GLI8SIERES. 

By  Albas  Dosan. 

This  instrument  haa  been  described  and  figured  in  the 
*  Contralblatt  fiir  Gyuafcologie,'  No.  18,  1890^  p.  324. 
Mr.  Duraa  stated  tliat  be  had  frequently  used  it^  and  found 
tbat  it  W03  a  good  foi-m  of  apeculam  in  mnuy  respects. 
First,  it  w(w  mode  of  metal  and  readily  cleaned. 
Secondly,  it  wns  of  the  form  of  Ferguason'a  instrument — 
the  best  for  geueral  use — the  easiest  wherewith  to  get  a 
good  view  of  the  cervix  uton.  Thirdly,  the  sliding  arrange- 
ment overcame  the  chief  disadvantage  of  Fergussoa's 
BpeculuiD.  Dr.  Delbastai tie's  instrument  was  split  into 
two  Halves  along  its  long  axis.  By  sliding  the  upper  half 
a  little  backwards,  after  the  cervix  had  been  brought  welt 
into  view,  more  room  oould  bo  gained  for  using  a  volseila, 
sound,  or  aay  long  aud  straight- handled  iostrutnent.  A)l 
who  used  Fergusaon's  speculum  recognised  how  incon- 
renieut  it  was  whenever  a  long-handled  instrument  had 
to  be  employed.  Dr.  Delbastaille's  speculum  could  ateo 
be  ueedliko  n  Sims's  "  duck-bill,"  aa  a  handle  was  made 
to  screw  on  to  one  half  of  the  metal  tube.  This  arrange- 
ment was  very  convenient  for  inspection  of  the  clitoris, 
vestibule,  meatus,  and  anterior  vaginal  wall. 


TUBAL   GESTATION   REMOVED   BEFORE 
RUPTCHE. 


By  G.  Ernest  HcRMAtf,  M-B. 

Thb  history  of  the  case  is  puhliehed  in   the  'British 
Modical  Journal/  beptember  27th,  1890.     The  points  of 


808 


PELVIC  OE0AN8  OF  A  PATIBST,  ETC. 


intcrost  in  the  epeoimen  wcro  (I)  its  remoTal  beforo 
rcplure ;  (2)  the  pa^tiont  had  been  pverionsly  cured  by 
operatiou  of  a  gestation  in  the  other  tube;  (3)  the  Joetns 
had  died  early,  and  the  placenta  bad  gone  on  growing. 

Mirroscapical  report. — Microscopic  sections  from  the 
wall  of  the  tubail  pregnancy  had  been  made.  Between 
the  wall  of  the  tube  and  the  amnion,  the  ifpace  was  chiefly 
filled  with  extravasated  blood,  in  some  parts  quite  recent, 
in  others  begiuniii^  to  be  organised.  Recent  blood  wan 
met  with  in  all  ptirts,  close  to  the  amnion  as  well  as  near 
tbo  wail  of  the  tube.  Aniidat  the  oitravasatod  blood 
chorionic  villi  could  bo  seen,  many  of  them  filled  with 
blood.  The  wall  of  the  tube  was  infiltrated  with  round 
cells,  but  not  thickly,  except  in  a  few  places.  The  ams- 
ouIeu*  bundles  were  more  separated  than  normal,  and  tba 
fibres  were  slightly  larger  than  usual.  There  were  spaces 
that  looked  like  the  lumen  of  glands,  but  had  no  epithelial 
lining-.      Ku  large  decidnal  colU  could  Lo  seen  anywhere. 


PELVIC  ORGANS  OF  A  PATIENT  DYING  FROM 
INJECTION  OF  ACID  NITRATE  OF  MERCURY 
INTO  THE  VAGINA  TO  PRODUCE  ABOR- 
TION.* 

By  JonN  PniLLirs,  M.D. 


Db.  Puiilifb  called  attention  to  the  site  of  the  infec- 
tion in.  the  Tafjinn,  the  untouched  tea  weeks'  ornm,  the 
congested  conditioQ  of  tho  right  broad  ligament  and  the 
general  -sloughing  of  the  rectdl  amcous  membrane.  He 
deferred  many  intereEting  points  in  the  case  to  n  fartlior 
contribution  on  the  subject. 

?or  ioquciit.  sve  'Time*,'  June  4th,  18M|  fur  trial,  Hid. 


CASE  OF  SYMMETRICAL  ERYSIPELAS,  FOL- 
LOWED BY  PREMATURE  LABOUR;  ECLAMP- 
SIA  ON  THE  NINETEENTH  DAY  POST 
PARTUM  ;  TWENTY-EIGHT  PAROXYSMS  j 
NO   RENAL   DISEASE;    RECOVERY. 

By  JAMIE80JI  B.  HoEET,  M.A.,  M.D. 

(Heceiretl  Febmarj-  IStb,  1B90.) 

E.  W — ,  tot,  35,  W-para  ;  pregnant  niao  uud  a  half  lunar 
months. 

September  7th,  1880,  noon. — Seen  for  the  first  time 
this  morning.  Her  previous  hiBtory  shows  freedom  from 
nenrotio  disease,  and  during  the  present  pregnancy  her 
health  has  been  good  until  this  momiog,  wheD  (without 
digcorerahle  cause)  the  following  symptoms  have  appeared  : 
severe  licadache,  pains  in  limbs  and  loins,  shiyering,  rapid 
pulse,  hot  fihin,  anorexia.  At  10.90  p.m.  she  was  suddenly 
delivered  of  child  before  arrival  of  doctor.  Placenta  ex- 
pressed a  la  CtpaU,  withont  a  single  vaginal  eiamiQation. 

8th,  2.30  a.m. — Post-partum  tfeinorrha^e  of  moderate 
Bovi-rity,  arrested  by  vigorous  kuoading  of  uterus  and 
large  doses  of  ergot.  A  siaglo  exploration  andortakon  in 
order  to  remove  clots  from  uterus,  il  a.m.  She  looks  ill, 
with  same  symptomB  as  on  September  7th. 

0th. — In  front  of  each  ear,  and  extending  perfectly  sym- 
metrically on  both  «ides  over  an  area  equal  to  that  of  & 
florin,  is  an  erysipelatous  eruption.  The  skin  over  tlie 
affected  area  is  hot,  tender,  swollen  and  pits  on  pressure, 
suggesting  at  first  the  possibility  of  deep-seated  suppura- 
tioQ.  No  resemblance  in  ether  respects  to  Rcarlatiaa. 
NoBore  throat.  Temperature  lOi'5®  F.;  pulse  125.  Lochia 
natural,  not  offensive. 

lOth.— PaticDt  seen  by  Mr.  George  May,  F.R.C.S.,  in 

consultation.     She  pi-oscnts  all  the  local  and  constitetional 

[Symptoms  of  erysipelas.     Tho  eruption  aSects  both  sides 


810 


BTHMETBIOAI    BBTSIFSLAS. 


of  the  Ence  sjmmotrlcAlly,  and  covers  larger  areas  thaa 
yesterday,  nlthough  these  areas  do  not  meet  in  the  median 
line.  Strict  antiseptic  precautions  orderod,  namely,  boracic 
acid  padft  (instead  of  diapers),  to  be  changed  as  rapidly 
as  possible  ;  carboHsed  steam  to  be  diffused  throagh 
room  ;  semi-recumbent  pnature  to  be  assumed  for  a  few 
minutes  twice  a  day.  Vaginal  imgations  forbidden ;  ven- 
tilation of  room  attended  to. 

lltb. — Erysipelatoas  eruption  has  spread  from  the  two 
areas  first  attacked  and  now  covers  most  of  the  faoe. 
The  coastitnt-ional  symptoms  are  very  severe.  Pulse  132  ; 
temperature  lOi  F.  a.m.,  IU3*  p.m.  Lochia  continue 
inoffenaive.  Uriue  free  from  nlbumen.  Suckling  discon- 
tinued, on  account  partly  of  the  risk  of  infection,  partly 
of  the  deficient  supply. 

12th. — Erysipelas  covers  the  same  extent  as  yesterday. 
Patient  is  taking  food  fairly  well.  TempeTflture  lOS'l"  F. 
a.m.,  lOi'-i*^  p.m,  Slight  tympanites  noticed  to-day  for 
first  time. 

13th, — Erysipelas  is  slowly  receding.  Lochia  natural. 
Abdomen  is  tender  and  tympanitic.  Temperatnre  102" 
a.m.,  104'6  p  m. 

17th. — Gradual  improvement  during  last  four  days. 
Temperature  is  slowly  falling.  The  abdominal  tenderness 
has  been  conaiderablCj  affecting  mainly  the  right  inguinal 
and  hypogastric  regions.  There  have  been  no  rigors  nor 
any  indication  of  septic  mischief,  except  the  abdominal 
tendepuesfi  and  tympanites  referred  to  above.  Ijoohia 
natural;  urine  normal,  free  from  albumen. 

2l8t. — The  tenderness  in  hypogaatrium  is  much  less 
marked.  Patient  looks  better.  Pulse  9S;  temperatnpo 
99"  a.m.  and  p.m. 

Daring  the  oext  four  days  patient  appeared  to  be  doing 
well  in  all  respects.  Her  temperature  had  been  normal  ; 
pulse  about  80  ;  tongue  clean.  The  abdominal  tendcruoita 
had  almost  gone.  Lochia  perfectly  natural.  Appetite 
good.  There  was  nothing  to  indicate  the  approaching 
complication. 


STMMETBICAL   ICRT8IPELA8. 


26th,  n  a.m. — Patleut  complains  of  Bevera  frontal 
he&daclie,  bat  otberwise  appears  to  be  doing  well.  The 
peeling  of  the  face  dae  to  the  erj-sipelaa  has  almost  ceased  ; 
but  there  is  a  serous  discharge  from,  and  deafness  of,  tha 
left  ear.  At  9  p.in.  she  wn.s  suddenly  censed  with  epilep- 
tiform coDTulsions  inyolviug  the  whole  body.  There  was 
total  lou  of  conecionsnosB ;  pupils  dilated,  giving  no 
reaction  to^lig^ht;  conjunctival  redox  abotiabed ;  slight 
foaming  at  mouth;  urine  passed  involuntarily,  £j  10 
p.m.  conscionancss  had  partially  returned. 

27tli,  0,30  a.m. — There  have  been  six  more  fits  this 
srning,  tbreo  being  very  severe,  the  last  occurring  while 
May  and  I  were  seeing  her  in  consultation  together, 
the  characters  of  eclaRiptic  convulsions  mentioDed 
above  were  preaeut.  Chloral,  gr.  L,  was  given  per 
reetum,  and  chloroform  inhalntions  ased.  8  p.m.  Bight 
more  fits  occiirrod  to-day  in  the  course  of  one  and  a  quarter 
hours,  bat  less  severe  than  those  of  the  morning.  During 
the  afteraoon  patient  has  lain  in  a  semi-conscioDS  condi- 
tion.    Temperature  normal. 

28th,  a.ra. — Three  more  fits  occurred  doting  the  night. 
Urine  passed  voluntarily  for  the  first  time  aioco  tho  onset 
of  the  (its  ;  it  contains  no  albumen.  A  careful  searcli  wag 
mode  for  any  cause  of  the  convnUive  attacks,  but  without 
encoess.  No  local  tenderness  or  pain,  except  headache. 
8  p.m.  Eiglit  more  fits  have  occurred  since  the  morning, 
but  of  much  lean  severity.  In  some  of  them  only  tho  facial 
musclea  were  involved,  and  conxciousneBE  was  only  partly 
loet.  Temperature  99-6'' P.  a.m.,  lOO'  p.m.;  pulse  100. 
The  nrine  was  tested  whenever  passed,  but  never  con* 
taincd  any  trace  of  albumen. 

October  2nd. — During  the  last  four  days  there  has  been 
a  complete  cessation  of  tho  attacks.  Patient  takes  nourish- 
ment fairly  well,  bnt  i^tiU  complaina  of  hfadacbe.  Mental 
powers  unimpaired.  The  discharge  from  the  ear  has 
ceased,  and  good  hearing  is  regained. 

]3tb.— Patient  is  well. 


SIS 

I 


STHHliTBICAli  SBTSIPBI 


Bemarhg. 


Ttis  case,  of  wliich  the  important.  fcaturcB  liave  juat 
buen  QArrtited,  is  of  peculiar  interest  from  ecToral  points  of 
view. 

Firstly.  Erysipelns  attacking  a  woman  immediately 
before  labour,  and  apparently  inducing  premature  delivery, 
is  in  itself  a  very  unuaual  event. 

Secondly.  So  far  a,&  I  am  aware,  no  ciwe  in  which 
erysipelas  has  attacked  opposite  aides  of  the  hody  simQl> 
taneously  and  symmetrically  is  on  record.  At  any  ratOj 
BO  rare  is  this  occurrence  that  at  the  famous  discussion  on 
"  Puerperal  Fever  *'  at  the  Ohstotrical  Society  in  1.875, 
Mr.  Jonathan  Hutchinson,  F.H.&.  (speaking  of  the  speci- 
ficity of  erysipelas}  declared;*  "We  never  see  it  (i.e. 
erysipelas)  prevail  symmetrically  in  the  two  halves  of  the 
body,  as  it  certninly  would  do,  if  it  ware  due  to  the  intwj- 
duction  of  any  specific  germs,  which  would  develop  io  the 
Baiue  manner  as  we  know  the  Epecific  poisons  of  smallpox, 
scarlet  fever  and  measles  do." 

In  thus  aflBruiing  that  erysipelas  may,  from  the  com* 
mencemeiit  of  the  cutaneous  eruption,  involve  two  sytn* 
metrical  portions  of  the  body  (and  I  would  point  out  that 
thiepatient  was  throughout  under  the  closest  observation), 
I  am  glad  to  have  the  confirmatory  testimony  of  ao  expe- 
rienced and  caatioQs  an  observer  ae  Mr.  May. 

Thirdly.  The  possibility  of  erysipelas  of  the  faco 
attacking  a  lying-in  woman  without  provoking  puerperal 
septicatmia  of  any  severity  is  also  interesting.  If,  as 
appears  to  be  established  both  by  cliuicat  observation  and 
bacteriological  experiment, f  the  same  virus  may  provoke 
erysipelari  and  puerperal  fever,  we  should  perhaps  have 
expected  that  a  lying-in  woman  suffering  from  erysipelas 
of  the  face  would  run  the  greatest  iiak  of  puei-peral  aepaia, 
and  yet  in  the  case  before  ub  uo  symptom  of  such  scpsia 

•  Cf.  'Obrtct.  Tnini...'  vol.  svii.  p.  118. 

t  Cf.  inttr  alia  Dojen't  cipcrluicuM,  iiuiiitDarin«l  in  '  Brit.  MmL  Joan.,* 
18tl«,),I>.  031. 


4 
4 


8YVUETEI0&L  BRT6IFBL1S. 


Rppcnred,  unless  wo  assigu  tbo  tympanites  Bud  tendoruess 
to  sccli  cause.  Witlt  thia  limitatiou,  her  symptoms  oorre- 
Bponilud  to  tboso  of  au  attack  of  fanal  eryaipolas. 

In  seeking^  for  a.  po5stb1e  explanation  foi*  the  imuiunity 
from  general  sepsis,  I  am  mnch  tempted  to  adopt,  as  nt 
least  a  useful  working  hypothesis,  a  sDggestiou  made  by 
Dr.  Playfsir*  in  regard  to  tlie  relation  of  zymotic  diseases 
to  puerperal  (ever. 

It  is  wotl  known  Low  various  ia  tho  experience  of 
accouchoura  in  regard  to  exaotheiuata  during  tlie  post* 
partam  state.  On  the  one  hand,  we  find  Spiegclbttrgf 
declaring  that  "  the  puerperal  virus  has  no  particular  con- 
nection with  the  poison  of  tho  acnt«  exanthemata ;"  and 
again  "  that  the  acpte  exanthemata  may  broak  oat  in 
lying-in  women,  and  even  in  those  attacked  by  septic 
diBeasex ;  but  when  they  do  so,  the  zymotic;  disea-ses  and 
the  piierporinm  or  the  puerperal  eopsis,  in  the  main, 
advance  quietly  side  by  side,  although  no  doobt  their 
characters  may  be  more  or  lesa  modified." 

On  the  other  baud.  Dr.  Braxton  Hicks]  holds  that  a 
puerperal  woman,  tvbcn  affected  with  scarlet  fever,  devotups 
puerperal  fever;  and  another  obstetrician,  Dr.  Tyler  Smith, 
declared  from  the  ch&ir  of  the  Obstetrical  Society^  that 
"  any  of  the  agents  which  produced  zymotic  maladies  might 
cause  puorporal  fever." 

A  different  view,  Agaiu,  is  hold  by  Dr.  West,!!  namely, 
that  the  acute  exanthemata  sometimes  breed  trae  in  the 
lying'in  woman — that  is,  variola  produces  variola ;  at  other 
times  tbey  give  rise  to  disease  indistinguishable  from 
puerperal  fever. 

Dr.  Playfair,  in  discussing  these  cases,  writes:  "It 
seems  to  mo  not  improbable  that  the  explanation  oE  the 
lad  that  zymotic  poiuon   may   in  one  paerperal  patient 


•  -Science  iini]  I^motioe  o(  Miilwifer;,'  1980,  11.  p.  340. 
f  New  Sjdonluua  9otaHj'»  tmAtlatioii,  il,  p.  iSt*. 
t  'OUlclrioal  TtuiMctiou,'  vol.  w,  p.  -H. 
S  lUd.,  tol.  ill.  p.  40S. 
lUd.,  TOl.  ivU,  p.  287. 


S14 


STHUSTRICAL    RRTSr PBf.AS. 


run  ite  ordinary  coarse,  and  in  another  produce  symptoms 
of  intoneo  septioocmia,  may  be  found  in  the  cbaunol  of 
absoi*ption.  It  is  at  any  rate  comprehonsiblo  that  if  tho 
contagion  bo  absorbed  through  tlio  skin  or  ordinary 
cbannel,  it  may  produce  its  cba.racteriatic  aytnpiotns  and 
run  its  nsual  course  ;  while,  if  brought  into  contact  witlt 
lesions  of  continuity  in  the  generative  tract,  it  may  act 
more  in  the  way  of  septic  poison,  or  with  such  intensity 
that  its  specific  characters  are  not  developed." 

"Without  for  a  moment  wishing  to  minimise  the  great 
diflSoulties  that  lie  in  the  way  of  onr  accepting  tliia  view 
(and  a  discussion  of  them  would  involye  such  moot  qnea- 
tionfi  as  the  local  or  con&titutiona]  nature  of  orysipelas, 
and  the  moaning  of  "specificity"  as  applied  to  zymotio 
disease),  yet  I  may  point  ont  that  the  treatment  of  the 
above  case  was  based  upon  it,  and  apparently  with  snocees. 
By  preventing  the  access  of  contagion  to  the  generative 
organs  by  antiseptic  pads  rapidly  changed,  and  by  dis- 
infecting the  air  of  the  room,  efforts  were  made  to  keep 
the  generative  tract,  so  readily  inoculated  in  the  poHt> 
partum  state,  free  from  the  virus  of  erysipelas. 

Fourthly.  It  is  very  unusaal  for  an  iiiter7al  of  nine- 
teen days  to  elapse  between  delivery  and  the  outbreak  of 
eclamptic  convulsions. 

Fifthly.  Recovery  after  so  large  a  number  o£  eolamptio 
ftttftoks  as  twenty -six  is  rare,  bat  by  no  means  unrecorded. 

Sixthly.  The  total  absence  of  albuminuria  or  other 
renal  symptoms  is  also  noteworthy.  The  nrin©  passed  in 
the  interval  between  two  rapidly  successive  paroxysms 
was  more  than  once  tested,  and  always  with  a  like 
result. 


Dr.  Bu&XTON  Hicks  wished  to  point  th&t  the  author  had  fallea 
into  a  mistnlte  wliicli  mauy  otbera  hud  made,  both  here  and  in 
America,  namely,  that  in  the  paper  he  had  brought  before  the 
Society  many  yeare  ago,  ahowing  the  clinical  aurromnlmKB  of  a 
nutnbor  ufcaaeB  ol'  puerperal  dmene^E,  he  bad  stated  that  puer- 
peral fever  was  caused  by  ecarlatina.  If  this  paper  were  carefully 
read,  together  with  his  remnrke  in  the  diBcuuion  of  puerperal 


SmRTGTC&L  ZETSIPBUS. 


fever  in  rela,tion  to  iufective  diseases  and  pyaemia,  it  would  he 
wen  tliat  hv  had  not  made  that  assertion.  He  had  endeavoured 
to  do  what  but  fi>w,  eucli  as  Dr.  Boxall  and  the  author  o£  this 
paper,  bad  done,  u&nicly,  to  being  facts  befwrB  the  Society.  lit  had 
endeavoured  lo  correct  this  niisapprelieiisiun  uf  what  he  had  Maid 
hy  publi«hiii?  nn  explanntion  iu  the  '  AiiJ«ri(.'aQ  Journal  of 
Obstetrics,'  Ma^,  1&88.  That  there  ia  an  intimate  counection 
botweou  zymotics, erysipelas,  &c.,  and  puerporBt  fever,  so  called, 
tlher«  could  be  no  doubt,  but  the  eiucrt  nature  of  the  relationship 
;et  had  to  be  made  out.  For  himeelf,  it  6oemed.  most  likely, 
according;  to  our  preaent  knowledge,  that  in  the  bad  coses, 
eimilur  to  thotte  seen  iu  hojtpitale  farmerly,  there  trere  two 
poiKona  acting  concurrently,  and  this  probability  was  pointed  at 
Dy  our  president  in  hia  addresn.  However,  Dr.  Hlihscuocltided 
by  saying  that  the  solution  of  ibe  quettion  could  only  be  found 
by  continually  colloctiufr  cUoiual  hieturica  from  all  part«  of  the 
world,  particularly  in  nevr  towaa  not  yat  saturatod  with  zymotic 
diaeaaea. 

Dr.  Hrbuait  said  that  Dr.  Hurry  took  it  bb  estnblished  that 
«ryiipelas  was  one  of  the  causes  of  puerperal  fever.  Thla  riew 
WM  based  upon  the  experience  of  certain  lying-in  hospitais  in 
Dublin,  Paris,  and  London,  in  which  the  preFtence  of  a  case  in  the 
hoitpital  or  itsneishbourhood  Lad  preceded  the  outbreak  of  puor- 
poral  fever.  In  King's  College  HoopiLal.  the  presence  of  cry. 
eipelas  in  the  surgira!  wards  had  been  found  to  go  along  with  fever 
in  the  lying-in  vrard.  But  lie  (Dr.  HormeD)  did  not  think  this 
by  itself  showed  more  than  that  the  tvru  diaeofies  flourisbed  and 
spread  under  ideutical  conditioua.  The  opinion  bnd  also  been 
supported  by  Dr.  Minor's  book,  in  which  he  compared  the  pre- 
Yalence  of  eryoipeias  and  puerperal  fever  in  difl'ereut  >»tate8  of 
America,  and  proved  to  hta  ova  satisfaction  that  the  two  diee&aea 
prevailed  together.  But  b«  (Dr.  Herman)  did  not  think  that 
the  evidence  adduced  by  Dr.  Minor  bora  out  his  conclusion. 
The  80>ca11ed  "epiclemica"  of  puerperal  fever  were  only  very 
alight  elevations  of  the  number  of  cnseei  above  the  general 
BTCTSge,  and  the  uumbor  of  times  that  on  iucreaeed  death-rate 
from  erysipelaa  went  with  an  increased  deatb-rutc  from  puerperal 
fever  was  not  more  than  could  he  accounted  for  by  lortuttous 
coincidence,  together  with  the  fact  that  the  spread  of  both 
diseases  was  favoured  by  uneleanliue»a  and  bad  ventilation. 
Thus  both  dineuses  were  found  eBpeeiftlly  frequent  among 
Gercnan  immigrants.  The  (Question  had  been  obscured  by  the 
inclusion  of  two  diifereDt  diseases  under  the  term  erysipelas. 
Cutaneous  eryeipias,  Hhich  Fcbleiseu  bad  Hhuwo  lo  depend 
upon  a  specific  coccus,  which  could  be  cultivated  and  inoculated, 
reproducing  the  disease,  was  quite  a  diflerent  thing  from  phleg- 
monous  erysipelac.  Phlegmonous  erjaipoUa  he  (Dr.  Herman) 
bad  no  doubt  waa  one  of  the  diaeasee  included  under  the  term 


816 


STlDIKTBICii   KBTBIPBLifl. 


poerpenl  ferer.    The  poison  of  thia  dieeitefi  produced  as  tcrribte 
eonSMuenct's  wheo  inoculated  into  a  rent  in  the  pcrinrcum  as  ib 
did  vnen  it  got  Juto  n  wound  in  a  limb.    Thin  nan  the  diaeaasi 
whicU  Virchow  hod  called  en/slpetat  maltjnum  internum.     Baft 
cutaneous  erysipelas,  when  communicated  to  a  )}-iug-ta  womAO, 
produced  ouly  the  siLine  dieease  as  it  did  in  any  other  patient. 
tiuBserow  had  published  a  series  of  cases  which  showed  this. 
He  CDf.  HermsQ)  had  seen  cutaniiouB  eryeipeliis  in  the  lyiug-ia 
woDi&n,  and  also  io  the  infant,  nnd  it  ran  juat  the  «ame  coursa 
88  in  a  patient  who  had  not  been  delivered,  s.nd  did  not  produoa  . 
puerperal  fever.     He  agreed  with  Dr.  Braitoa  Hick»  that  caaei^ 
m  which  [latieotB  appeared  to  Buffer  from  erysipeias  and  front 
septicaemia  were  cases  of  mised  infectious,  lu  nliich  the  poisoa 
of  both  diaeaaea  had  been  received  by  the  patient. 

Dr.  Heiwooi)  8MiTti  wislied  to  koow  if  an;  obserratioDa  had 
been  tnlsen  of  the  frequency  or  character  of  the  pulse  between 
the  fits. 

Dr.  BoxAiL  said  that  the  subject  so  ably  pTeaented  to  the 
Society  by  Dr.  Huri-y  was  to  tiiiu  of  peculiar  personal  interest. 
Indeed,  it  will  be  found  to  occupy  a  protaiueDt  place  ia  tlie 
next  part  of  bia  paper  on  "  I'ever  in  Cbildbed."  On  that  account 
he  would  uot  at  present  detail  the  evidence  which  he  hoped  at 
no  diBlaat  date  to  lay  before  the  Society.  At  the  same  time,  he 
visLed  to  take  the  present  upportuuity  of  niakiog  a  few  remarkt 
of  a  general  characler  on  Bome  points  in  the  paper.  And,  at  the 
outset,  he  would  draw  a  diatiuctiou  betw^eea  facial,  and — a«  it 
might  be  termed — pelvic,  erysipelas.  For,  though  couvinced 
tfant  both  were  due  to  tlie  aanie  cause,  he  uevertlieless  recognised 
that  the  difference  in  the  primary  site  of  the  local  mflaminatioil 
entailed  great  divergence  ia  the  di  nical  aspect  and  gravity  of  such 
cases.  Facial  erysipelas,  such  iis  the  author  had  described, 
judging  from  the  literature  of  the  eubject,  was  aa  common  bofora 
ae  after  labour ;  even  more  so.  But  after  delivery  pelvic  err- ' 
■ipelas  held  the  first  place.  In  speaking  of  the  latter  he  would 
have  occasion  to  draw  attention  to  Winckel's  work,  '  Cber  da* 

fuerperaleEryeipel,"  which  formed  loost  inatnictive  reading  and 
rought  this  point  into  prominence.  For  the  present,  however, 
he  wiahed  to  limit  his  remarks  almost  conclusively  to  eryaipela*  , 
primarily  iiUackiug  the  face.  That  such  a  febrile  illneae  aa  ery* 
eipelaa — facial  eryaipelaa— was  competent  to  induce  premature 
la  hour  was  well  known,  and  many  such  occurrences  were  on  record. 
Dr.  Boxall  would  ask  the  author  if,  for  purposes  of  future  refer- 
ence, he  could  give  tiie  duration  of  the  pregnancy  la  days,  dating 
from  the  end  of  the  last  menstrual  period.  From  a  study  of  the 
literature  of  the  subject  (which,  however,  he  had  Dot  yet  ex- 
hauated)  Dr.  Boxall  was  disposed  to  agree  that  the  bihiteral  and 
■imultaoeouHappearanceoftae  erysipelatous  process  was  probably 
unique,  though  to  him  it  aeemed  a  poBsibility  which  might  at  any 


SYUMETBtCAL    ERTSIFELAB. 


317 


timo  occur.  By  way  of  analogy  he  might  instance  tbe  rare  occur- 
reiiL-e  of  wbitlow  on  both  bunds  pimultaQeousty.  To  hie  mind 
whitlow  and  fncial  eryeipcLns  preepnted  so  many  pointe  in  comtnotl, 
that  contemplation  of  the  behavtour  of  the  former  might  serve  to 
render  plain  the  after-course  of  the  latter.  To  begin  witb,  the 
chance  of  finding  a  local  breach  of  surface  was  about  on  a  par  in 
botb  casee.  Iti  both,  the  Qtrt;i.-tion,  tbcui;b  attended  with  a  certain 
amount  of  couBlitutiocal  iii§turbance,  waa  primarily  local,  but  it 
might  ultimately  become  general,  or  lead  to  the  establisbment  of 
otlier  inflamiQatory  foci,  sucK  aa  aometimea  occurred  in  tbe  {>elvi8. 
Further,  this  local  pelvic  iuflauimRtiou  might  ensue  in  one  of  two 
ways.  Id  the  case  of  whitlow,  septic  poiaon,  and  in  that  of 
facial  eryeipelaa,  erysipelatous  poieon,  might,  on  tbe  one  band, 
Bprend  from  its  original  liabitat  through  tbe  tissues  of  tbe  body 
and,  lighting  upon  already  damaged  pelvic  tiNSUoe,  produce  an 
acute  loriu  of  inflammation  ;  or,  on  tbe  other  band,  from  tbe  fame 
local  foci,  either  poison  might  be  given  off,  and,  after  escaping 
entirely  froin  tbe  body,  re-enter  it  through  the  genital  tract, 
bocotnoahRorbcd,  and  $et  np  in9nmm,ition  in  the  pelvi#.  To  tbe 
remarks  of  tho  author  under  the  third  beading,  Dr.  Boxall 
wished  to  direct  particular  attention.  In  the  first  place,  he  (Dr. 
Bosall)  was  willini*  to  regard  the  coee  in  point  as  being  tn  all 
probability  one  of  facial  erysipelaB  per  ae.  For  it  was  his 
opinion  that  bad  the  pelvic  organs  become  iovolred  ia  the 
eryaipelatou*  proceiw,  and  bad  pelvic  erysipelas  pesulted,  the 
physical  siKDS  (such  na  the  tympanitcit  and  tenderneas)  would 
probably  have  been  more  pronounced,  and  the  case  would 
flltogother  haveaaanmed  a  graver  aspect.  In  the  second  place — 
and  in  this  he  must  necessarily  trench  somewhat  on  the  evidence 
to  be  brought  forward  in  tbe  second  part  of  his  paper — he  was 
convinced  that  the  erjsipelatiins  poiaon  itself,  whan  it  implicated 
the  I'ehic  orgunn,  pruJucL-d  a  local  and  general  diaturbuDcc, 
which,  as  far  as  clinical  ob-^ervalion  was  concerned,  was  wry  often 
indistinguishable  from  puerperal  fever  as  generally  understood, 
and  invanably  resulted  in  a  puerperal  disease  of  grave  and  often 
fatal  type.  It  appeared  well  estublisbed  that  no  blush  appeared 
beyond  the  vulva  in  many  such  caics,  and  consequently  theip 
erysipelatous  character  was  apt  to  pasa  obaorvation.  On  the 
other  band,  lie  might  add  that  ne  waa  far  from  believing  that  all 
puerperal  fever,  or  gvod  nil  pucrpernlfevt-r  of  the  graver  kind,  waa 
6ryeip«IatouB,bficauaeothcr  poisons,  which  wereeeptic  butnotery- 
sipelatotis,  were  capable  of  producing  a  similar — lie  might  almost 
•ay  identical' — clinit^al  rextilt.  Now,  granting  that  erysipelatous 
ptUMD  tnigbt  itself  produce  a  form  of  tiuerperal  fevec  (in  Tcality 
■n  fttteck  of  erysipelas  tDdiBtingutshotle  in  diniciil  aspect  from 
septicemia  with  pelvic  inflammation),  we  certainly  should  have 
expected,  u  Dr,  Hurry  said,  that  a  lying-in  woman  sufiering 
from  eryeipelas  of  the  lace  would  run  the  greatest  risks  of  puer- 


818 


STMUETBICA^L    BRT8IPELAS. 


perol  sepBis.  ^fany  sach  cases,  howerer,  ver«  reported  in  vliich 
tbe  erysipelatouB  poison  fniled  to  reach  tlie  pelvis  either  by 
extending  through  the  bady-tisaue«  or  by  direct  reintroductioa 
through  the  genital  paeeages,  eepeciallf  where  such  meaaures  as 
tho«e  referred,  in  the  paper  were  adapted.  Finally,  with  rcg&n] 
to  the  working  hypotheeis  mentioned  by  the  author.  Dr.  Boxall* 
while  agreeing  th&t  it  held  go^d  in  the  ewe  oE  erysipelas 
trusted  that  we  should  soon  henr  the  last  oF  it  as  applied  to  th0 
aymotio  diaeaaes  generally.  For  he  reutured  to  say  that,  if,  aa 
bad  been  done  by  hiiuei^lf  in  the  c^iee  ot  acarlatiuu,  a  eeparato 
seriea  of  cMeti  of  eiich  of  the  zymotic  diseases  had  been  collected 
ID  which  the  eoiiree  of  infection  could  be  arrived  ut  with  sotne 
approach  to  certainty,  it  would  be  found  that  many  of  tbe  rerv 
worst  Cftses,  and  caaes  of  a  marked  character  were  those  id  which 
direet  iooculation  could  be  comptetely  eliiaiuated.  This  was  chieSy 
due  to  tbe  fact  that  in  many  auch  ca^es  tbe  pntient  had  obvioiuly 
received  infection  prior  to  the  onset  of  labour,  and  then  iu  all 
probability  through  the  ordinary  channels.  And  seeing  that  there 
BtiU  reuituned  similar  anomalies  which  could  not  be  explained, 
even  when  these difeoseeoccurrod  apart  from  puerpery,  anomaliea 
to  which  ohvioualy  no  theory  of  direct  inoculation  through  th« 
genital  tract  could  poBBibly  be  applied,  Dr.  Boxall  would  prefer 
to  await  patiently  a  rational  explanation,  to  seeking  solace  in 
so  groundless  a  tlieory.  Tbe  confusion  which  had  iu  no  small 
measure  ariaen  through  arguing  from  one  dieeaee  to  the  other 
— through  concluding  that  because  erysipeUa  did  tlii»,Bi-arIatina 
must  doTitewIae  and  measles  follow  in  the  same  train — would  only 
be  obviated  by  keeping  fhe  bebnviour  of  each  disease  separately 
before  the  mind.  And,  at  leaet  as  regarded  erysipelas  and  suurla- 
tina,  be  was  convinced  that  a  very  wide  difference  existed  in  their 
tendency  to  implicate  tbe  pelvic  organs  when  the  dieeoae  attacked 
a  recently  delivered  woman. 

Dr.  Amasd  RoiTTn  thought  that  as  there  was  distinct  ©ti- 
denee  of  otitis,  the  convulsions  were  due  to  a  transient  meDio^ 
f;itie,  eeccndary  to  the  erysipelas,  and  were  Qot,  in  aoy  etiological 
sense,  puerperal. 

Dr.  Cletelami)  disagreed  as  to  tie  analogy  between  culanoous 
facial  erysipelas  and  whitlow.  From  what  he  had  seen  of  both 
BfTectioDB,  there  was  do  tendeucy  to  suppuration  in  the  former, 
while  in  the  latter  it  was  marked.  He  h.xd  always  regarded  the 
importation  of  pus  into  puurpend  surroundings  as  an  element  of 
danger,  and  could  understand  the  Deces&ity  for  taking  pre- 
cautions  if  a  lying-in  woman  happened  to  be  suffering  from 
whitlow, 

Br.  Hc&BT,  in  reply,  thanlted  the  Society  for  the  kindly 
reception  accorded  to  his  paper,  which  was  a  small  contribution 
towarda  the  settlement  of  some  difficult  problems  in  obstetrica. 
To  Dr.  Braxton  Hiuka  au  apology  was  due  that  Jbia  TJewa  bodC 


820 


FOUR  CAiSES  OF  PREGNANCY  WITH  BRIGHT'S 
DISEASE. 

By  G.  Ernkst  Herman,  M.B.Lond.,  F.II.C.P., 

ODSTSTSIC  PHrtlCIAN  TO  TUX  tOITDOK   UdlPITJU. 


Beccivctl  JoDuary  11th,  1990.) 
{Ahstrael.) 

The  a.uthor  points  out  that  to  under3ta.Qd  the  relation  betwc^a 
renal  diseaBf  iu  [ireguftnt  woiiif  u  ami  cclauipaia  of  pregnancy,  it 
is  Deceesar;  to  roinpare  ccises  of  renal  clia^rtso  with  wlaiapsta 
with  ciLses  of  renal  disease  without  eclampain.  Four  caiiftx  of  Hie 
Ifltter  kind  are  defailed  iu  tliis  paper,  of  which  the  chi«f  fcaturei 
are  as  follows : 

Case  1, — Second  prognancy-  Morning  Biokneaa  ceasing  n1>out 
middle  of  third  month:  Tomiting  rftuming  in  seventh  montii, 
together  with  cedema,  giddineas,  amblyopia,  ind  disturbed  ttleep : 
slight  iLDsetuia  ;  att  marked  oardiiLc  hypertrophy :  urine  solid 
with  albumen:  quantity  of  uriae  iQcreased  :  excretion  of  urea 
Blightly  hfllow  the  «venigL»;  induction  of  labour  ncAr  cod  of 
seventh  month  :  child  living  :  rapid  diuLination  of  albuminuria 
fLud  tucrease  of  urea-excretion  following  delivery  :  recoverv! 
subsequent  preijiiaucy  without  similar  renal  changes. 

Casb  2. — Sixth  j)regii.ancy.  Twine:  hydratumoe:  a-dema  in 
last  fournionths  of  pregnancy  :  no  other  symptoms  :  nrino  solid 
with  albumon,  about  half  paraglobulin :  slightly  dimiui8hi>d 
quantity  of  urine  and  urea:  labour  acct'lemted  by  separution  of 
membianea  around  o»  uteri:  children  living:  delivery  imm^ 
dJotely  followed  by  great  dimiaution  in  albuminuria,  greaftj 
diui-eais,  and  augmented  urea-elimination:  temporary  return  of ' 
albuminuria  during  latter  part  of  lyiug-iu  period  :  apparently 
complete  recovery. 

Cas&  3, — 8u[teoath  pregnancy.     Fits  after  coufinemeat  six 


PRBQNANCY    WITK    BRIGHT  S    DISKA^SE. 


321 


Vflara  previoiislj" :  syraptoma  comiug  nu  at  beginniTiE;  of  ciglitli 
uoulk  of  proacut  pregnancy:  iotra-uieriae  death  o£  fcBtiia: 
premature  labour  induced  at  end  of  eighth  month,  after  one  week's 
trmtmetit  by  rest  and  milk  diet :  no  diminutioD  in  quantity  of 
iirine.but  diniiniHlieduiea-eliaiiuation  :  albumtiiurla:  diminution 
of  alltuniiuurta  and  partial  reaturatian  of  uroii-excretian  before 
delivery,  fioutinuiiag  after  deliverj:  recovery,  bat  persiateuco 
of  renal  diseaae. 

Cahx  4. — Albuminuria:  unemic  twitcbings  :  cerabral  bsmor* 
rbagc  :  induction  of  labour  at  bi-^nuiag  of  eighth  montb:  cbild 
liriog:  dimiuisked  percentage  of  urea  bcfuru  dclirory:  after 
delivery  rapid  increaee  in  percentage  of  urea,  and  temi-orary 
diminution  of  albuminuria :  renewed  cerebml  heomorrbage: 
coma  :  death :  no  antopi;. 

The  iiutbor  <^omnient8  on  Ibo  special  features  of  each  case: 
the  dimiuisUed  albuminuria  and  increased  urea-escretioa  wbicli 
followed  dolivory  in  uU  ;  these  cffeeta  of  deHvei7  being  greatest 
in  Case  2.  in  wbieb  the  abdominal  distention  was  greateat,  and 
least  in  Case  3.  in  wbicb  the  ahdoniinal  enlargement  was  least; 
Cue  i  being  also  contraetod  with  others  as  to  the  amount  of 
ftlbiunea,aud  the  duration  and  persistence  of  the  disease. 


1  have  in  former  communieationa  put  before  the  Society 
ca«e«  of  eclampeiu  in  wbicb  the  condition  of  tbd  renal 
fanction  was  noted  with  especial  care.  But  in  order  to 
ooderstand  what  part  aUeralioDs  in  renal  function  play  in 
the  production  of  eclampsiu,  wc  must  compare  tiuch  cases 
wibh  others  in  which  there  is  renal  disease  wtthoat 
eclampsia.     In  tli)9  p&per  I  sabmit  booiq  cases  of  this  kind. 

Case  1.  Second  pregnaney ;  morning  sithxeaa  ceavmg 
about  middle  of  third  month  ;  vomiting  returning  in  seventh 
monlh,  together  toith  ^dema,  giddinea*,  amblyopia,  and 
disivrbed  aUeji ;  slight  anfemia  ;  no  marked  rardiae  hyper- 
trophy ;  urine  gnlid  with  albumm ;  quantity  of  urine 
inerea»ed :  excretion  of  urea  iilighlly  below  the  average; 
induction  of  labour  near  end  of  seventh  moiith  ;  child 
living  ;  rapid  diminution  of  albuminuria  and  increase  of 


TOI..  UXlt. 


23 


PBC0H&NC7  WTTB  BRISST  8  HISEASS. 


urea-*9.eretion  following  delivery ;  recovery ;  subsequent 
pregnancy  withonl  »imilar  renal  changes  (from  notos 
by  G.  A.  Pratt,  House  Physician). 

F.  P— ,  single,  pregnant  with  second  ohi]d_,  admitted 
into  tha  Geneml  Lying-in  Hospital,  April  5tb,  1888. 

Previous  htstorj/. — No  scarlet  fever  or  any  other  illness. 
First  child  bom  PeWuary  2ud,  1885;  pregnancy  normal. 
Can  gire  no  account  of  confinement,  as  slie  was  delirered 
under  anseethetic.  Child  liad  spina  bi6da  and  club  feet. 
Began  to  menstruate  at  thirteen,  but  catainenia  did  not 
reappear  for  some  months,  after  which  Hieywere  regnlari 
moderate  in  quantity,  lasting  three  days.  No  pain.  Lust 
menstmated  during  second  week  iu  August,  1887,  qaantity 
as  usual.  Thinks  she  became  pregnant  the  day  after 
cessation  of  Sow.  About  a  fortnight  after  last  menstrua- 
tion, nausea  and  retching  came  on  immediately  on  rising 
in  the  morning,  which  continued  till  she  romitod.  This 
ceased  after  lasting  two  months,  bat  returned  in  Marcli, 
1868,  about  three  week»  before  admission,  Toinitiug 
occurring  on  fire  or  six  tnomings,  and  ou  two  occasions 
daring  the  night.  Since  Christmas,  patient  has  had  to  get 
out  of  bed  three  or  four  times  during  the  night  to  pass 
water,  passing  ouly  small  quantities,  with  some  pain, 
at  each  act.  Her  legs  have  been  swelling,  especially  at 
night,  for  two  months,  bat  only  slightly  until  the  first  week 
in  March,  1888,  when  patient  had  to  leave  her  work  one 
day,  owing  to  the  swelling  of  her  legs  and  giddineea. 
The  vulva  aiso  swelled,  and  her  face  has  been  swollen 
during  last  week.  There  has  been  ocoasional  dimness  of 
sight  during  the  last  week.  Patient  has  had  a  yellow 
vaginal  discharge  during  the  whole  of  pregnancy,  but 
during  the  last  two  mouths  it  Las  been  &o  free  that  a 
diaper  had  to  be  ased  continually.  No  headache,  but  a 
sharp,  almost  coutinuoua,  pain  in  each  tetnporal  region. 
For  some  weeks  past  has  not  slept  well. 

On  admignon  (April  5th). — Patient  was  pale  and  pasty 
looking.  No  marked  ansemia.  There  was  cedema  of 
both  lower  extremities,  extending  as  high  as  the  gn)in« 


PBEOSAKCt  WITH   BBIQHT'B   DISSASB. 


323 


on  either  side.  No  oedema  of  abdominal  walla.  Greatest 
abdominBl  girth  30^  inches.  FqdcIub  uteri  2^  inches  abo7e 
nmbilicus.  There  was  marked  uterine  obliquity  to  the 
right,  which  altered  with  the  position  of  patient,  being 
towards  the  left  when  pationt  had  been  lying  on  her  left 
side.  Fcetnl  benrt  audible.  Ci\rdiacdu]no3S  not  increased. 
Apex-beat  to  inner  side  of  left  nipple.  Eedaplioation  of 
first  sound  at  apex,  aecond  sound  loud  and  sharp  at  base. 
No  abnorinal  eigua  in  lungs. 

Oo  vaginal  examination  the  portio  vaginalis  was  found 
to  be  I  in.  long.  The  os  externum  admitted  the  tip  of  the 
finger,  bot  os  intemum  was  closed.  Vertex  presenting, 
freely  moveable.  Promontory  of  sacrum  not  felt.  Ex- 
ternal conju^^ato  7  in. 

OphthaliQological  examination  showed  no  morbid 
changes.  Patient  to  be  kept  in  bed,  on  milk  diet,  and 
allowed  plenty  of  distilled  water  to  drink.  Pulv.  Jalapre 
Co.,  gr.  XXX  given.  Uriue  to  be  drawn  o£[  by  catheter 
beforo  each  stool. 

April  7th. — There  being  no  change  in  condition  of 
patient,  the  uBUal  autiseptic  precautions  having  been 
taken,  a  No.  10  gnm^elastic  bougie  was  introduced  between 
the  uterus  and  foetfl.1  membranes  at  10.30  p.m.  At  11.15 
p.m.  a  small  quantity  of  liquor  amnii  began  to  escape. 

8th,  6  p.m. — Paiaa  regular  every  ten  minutea.  Pre- 
sentation second  cranial. 

9th,  2.15  a.m.— Os  fuUy  dilated.  2.30  a.m.  Child  born. 
Very  little  hsmorrhago,  in  all  about  3  oz. 

Child,  male,  17  inches  long,  weighed  3  lb.  3  oz.  Pla- 
ceEta  weighed  13  oz. 

The  lying-in  period  was  satisfactory.  The  oedema 
passed  off  rapidly  after  delivery.  On  the  third  day  it  was 
very  slight. 

During  first  weok  patient  frequently  complained  of  pain 
in  temporal  regioD.<j,  and  also  in  region  of  sternum. 

On  the  eighth  day  puitivnt  hat:!  6sh  diet,  and  on  the 
ninth  moat.     She  was  now  allowed  to  sit  up. 

Fationt  had  a  fair  quantity  of  milk,  which  was  drawn 


PBIOHAHOr  -WITH    BBtOHT'e   DISBASB. 


325 


off  by  breafit-pnmp  and  cIiiH  fed  with  it,  it  beiog  too 
weak  to  suck.  The  child  waa  placed  in  the  incubator, 
&nd  took  its  food  well. 

Temperature. — Up  to  the  time  of  delivery  the  tempera- 
ture was  nonnnl  or  sabnormal.  Three  hours  after  delivery 
it  roachod  100°,  but  soon  fell  agaio  to  normal ;  on  the 
Bvening'  of  tho  second  day  it  re&ched  101*2°,  which  was 
"probably  caused  by  some  slight  breast  Ironble,  as  it  soon 
fell  to  noriUBl.  During  the  whole  of  patient's  stay  in  the 
Iiospitat  the  temperature  was  taken  every  fonr  hours,  bnt 
it  remained  normal  until  her  discharge. 

Urine. — During  the  whole  of  patient's  stay  in  the  hos- 
pital the  ariQe  was  messored  every  twelve  hours  and 
examiced. 

At  first  nil  urine  was  drawn  off  by  catheter,  but  this 

was  diecoatiouod.  two  days  after  delivery.     After  this  the 

nrino  was  passed  by  the  patient  and  saved  by  the  nurse  j 

bat  the  catheter  was  used  immediately  before  the  bowels 

^were  going  to  act,  so  that  very  little  urine  was  lost. 

Quaiitilj^. — Up  to  the  time  of  delivery  the  average 
quantity  of  urine  passed  per  diem  was  61  oz.,  bub  the 
daily  variations  were  great.  Before  delivery,  the  largest 
|D&stity  pasNed  in  twenty-fonr  hours  was  8i  oz.  and  the 
'■minimnm  was  in  the  twenty-four  hours  jnat  before  do- 
livery,  when  only  44  os.  were  passed.  In  the  twenty -lour 
hoars  following  delivery  the  quantity  rose  to  72  oz. 
On  the  second  day  after  delivery,  the  qoantity  was  67  on. 
in  twonty-fonr  honrti,  bat  on  the  foarth  day  it  fell  to  26  ok. 
Oq  the  sixteenth  day  after  delivery  the  patient  passed  a 
large  quantity  of  limpid  uHdo,  113  os.  in  twenty-four 
hours,  this  being  probably  due  to  emotional  causes ;  and 
on  the  neventronth  day  65  ox. 

Sjieci^c  gravity. — On  admission  it  was  1008 ;  the  day 
before  delivery  it  rose  to  1015,  and  immediately  after 
delivery  it  rose  to  1020,  which  was  the  highest  reached. 
,. After  this  it  varied  from  1008  to  1018  ;  but  on  the  seven- 
teenth day,  when  the  large  quantity  of  arino  was  passed, 
tbe  &p.  gr.  fell  to  1004. 


S2« 


FREaNAHCY   WITH   BBIOBT'S  D1BEA8E. 


Albumen. — On  admission  the  first  urino  examiood 
turned  solid  on  boiling.  Next  day  it  waa  one>fifth,  and 
the  day  before  delivery  a  half.  After  delirery  the 
quantity  of  albumen  at  once  fell  to  one  quarter,  and 
coDtinued  steadily  dimiDisliiDg,  bo  that  on  the  sixth  day 
after  delivery  there  was  only  a  trace.  A  very  faint  cload 
-was  atill  seen  viheu  patient  wae  diecliarged.  The  albumen 
did  not  increase  when  the  patient  began,  to  take  ordinary 
diet,  nor  when  she  got  np. 

Casta, — Urine  contained  a  few  hyaline  and  granular 
casta,  but  they  were  never  numerous.  They  were  slightly 
more  numeroua  immediately  aft«r  delivery  than  before. 

Urea. — The  urea  was  Gstimated  twice  daily  during  the 
whole  Gtay  in  the  hospital  by  Squibb's  apparatna.  On 
admisEion,  the  urine  only  contained  0' 7  per  cent,  and  re- 
mained so  daring  the  £rst  day,  the  patient  passing  244 
grains  of  nrea  in  twenty-four  hours.  In  the  twenty-four 
hours  preceding  delivery  she  passed  ]90  grains  of  urea. 
Immediately  after  delivery  the  quantity  rose  to  262  grains 
in  twenty-four  houra ;  on  the  eighth  day  to  606  grains. 
After  thiB  it  varied  between  420  and  550  grains  in  the 
twenty*foar  hoara.  On  the  day  in  which  the  largo  qnan- 
tity  of  urine  was  passed  the  percentage  of  uren.  for  twenty- 
four  hours  fell  to  'Si,  but  rose  again  the  following  day. 

On  April  26th,  1S88,  the  patient  was  sent  to  the  con- 
valescent home. 

Her  urine  was  examined  on  May  2dth,  1888,  and  still  con- 
tained a  faint  cloud  of  albumen,  and  1*22  per  cent,  of  urea ; 
she  passes  about  three  pints  in  the  twenty- four  hours. 

December  16th,  1889,— Confined  NovembBr24th^  1889— 
she  thinlcs  at  about  three  weeks  before  her  time.  Last 
menstraation  ceased  Dec.  lOth,  1888. 

During  pregnancy  frequently  came  over  with  a  "  Hilly- 
feeling,"  not  headache,  but  a  peculiar  feeling  in  the  head. 
Much  more  vomiting  than  in  the  former  pregnancies. 
Went  to  St.  Olavc'B  (Southwark)  Workhouse  about  Novem- 
ber 8th.  Urine  was  tested  by  Dr.  P,  P.  Wightwick  soon 
after  admiesion,  and  a  trace  of  albumen  found.     Labour 


PBKOITANOT   WitHBRrOHT  0  I1WKA8E. 


327 


lasted  ubout  six  hours.  The  liquor  amnii  was  discharged 
twenty-Eonr  honrs  before  pains  began.  No  anasarca  nor 
ascites  while  io  tho  workhouse.  Urine  alwaye  contaiacd 
a  trace  of  albotnoa.     No  convukioDs. 

Pationt  is  thin :  not  markedly  anssmic.  No  (sdema. 
Heart's  apex-beat  below  nipple.  No  marmtir.  Feek 
urell  except  that  Bhe  thinks  ebe  is  weak.  Urine  sp.  gr. 
1020,  scid,  trace  of  albumen;  a  few  granular  cants. 

Labour  was  induced  in  this  case  for  the  sake  both  of 
the  mother  and  the  child.  For  the  sake  of  the  mother, 
becaase  to  allow  the  pregnancy  to  go  on  would  have  been 
to  expose  ber  to  increu^^ed  risk  of  (.•clampsia,  and  increased 
probability  of  renal  disease  persisting  after  delivery  :  while 
experience  has  abundantly  shown  that  in  renal  disease 
coexisting  with  pregnancy  rapid  improvement  ueually 
follows  deliTcry.  For  the  sake  of  the  child,  becaase  much 
evidence  has  been  brought  forward  by  Fehling^*  Wiedow,t 
Cohnjt  and  others,  to  show  that  in  Brigbt's  disease  with 
pregnancy,  intra-aterine  death  of  the  foetaa  is  frequent : 
and  cascR  which  I  have  published  show  the  samo  thing. 

In  this  case  the  excretion  of  nrea  before  delivery  was 
a  little  more  than  half  the  average  of  health.  This  was 
probably  largely  an  effect  of  restricted  diet,  for  the  daily 
quantity  waa  only  slightly  increased  by  delivery,  but  rose 
to  tho  full  average  of  bealth  when  the  patient  was  put  on 
moat  diet. 

Some  diminution  in  the  albuminuria  followed  rest  and 
milk  diet,  but  the  quantity  was  increased  again  before 
delivery.  After  delivery,  as  ih  almoRt  invariably  the  case, 
there  was  a  rapid  diminution  in  the  amount  of  albnmen. 

Although  a  trace  of  albumen  in  the  arino  remained,  a 
further  pregnancy  was  not  attended  with  a  recurrence  of 
similar  kidney  change. 

Cask  3.  Sixth  pregnancy  !  ttetntt;  hydTamnio* ;  adema 
in  iaat  four  months  of  pregnancy  ;  iio  other  gymiitoma  ; 

•  '  Aroh.  fflr  Oyn.,'  Banil  xxvn. 

t '  Z«iU.  fttr  0«b.  UDd  O7B.,'  Band  xlv. 


ftas 


PBEONAKCr   WITH   BKiaBT's   DISBASS. 


urine  noUd  joitk  albumen,  about  half  paragtobuUn  •  alighthf^ 
diminished  qitantity  of  urine  and  urea;   lahuur  aaselerataA 
bjf  separation  of  meinhranes  round  o» ;    ckildr«H  living  ; 
delivery  iriirnediately  followed  ly  great  diminutian  in  aSntmi 
minuria,  great  diureeis,  and  augmented  urta-elimiiiation  j 
tomporary  return,  cf  albuminuria  dwrtJtj    latter  pari  of 
tying-i?i  period  ;  apparently  complets  recovery. — B,  A — , 
aged  36,  admitted  into  the  London  Hospital  uuder  the 
care  of  Dr.  F.  Charlewood  Turner,  May  17tli,  1888.     {I 
have  to  thank  Dr.  Tnrnot'  for  calling  my  attention  to  this 
case,  and  for  permitting  me  to  pnblieh  it  j  and  Mr.  G.  C. 
Wright,  Resident  Accoucheur,  for  the  notes  and  for  the 
meaearoment  and  oxamination  o£  tho  urine.) 

Patient  Bs.id  she  had  been  married  ten  years,  and  bad 
had  five  children,  all  living,  and  one  miscarriage.  She 
worked  aa  a  tailoress.  Haa  had  no  previous  illness. 
Believea  heraelf  near  the  full  term  of  pregnancy.  Foot 
months  ago  began  to  suffer  with  crauip  in  tlio  legs,  and 
then  the  legs  began  to  svrell,  and  tho  swelling  has  since 
continued  and  increaeed.  Has  had  no  pain.  No  vomiting. 
Appetito  moderate,  bowels  confined.  Has  slept  well.  Ho 
headache.     No  defect  of  sight. 

On  admission. — Patient  was  well  nourishod,  but  anasmic. 
Legs  and  lower  abdomen  were  osdematDus.  Cardiac  dol- 
nesa  increased,  but  no  mnrmar  ;  pulse  75.  Nothing  ab- 
normal on  ophthalmoscopic  examinalion.  Abdomen  greatly 
distended  and  flnctuatring.  The  urine,  when  albumen  was 
precipitated,  became  nearly  eolid. 

Dr.  Herman  saw  the  patient  on  May  22nd.  Tho  os 
uteri  waa  then  tie  size  of  half-a-crowD,  and  tho  head 
could  be  felt  presenting.  The  patient  did  not  complain 
of  pain. 

May  23rd. — Still  no  pain.  Os  uteri  same  size.  Fcctai 
heart  beard,  over  150  per  minnte. 

26lli.- — Couditiou  tlie  same.  Tiio  following  measnre- 
menta  were  made : — Circumference  at  umbilicus,  47  inches; 
ensiform  cartilage  to  ambtlicus,  12{  inches;  pubeg  to 
nmbilicns,  9^  inches.     At  about  2  p.m.  the  membranes 


*CY  WrrB   URtOHf'fl  DTI!! 


32? 


TTcro  soparated  by  the  finger  as  far  round  the  os  ateri  as 
tho  fingor  could  reucb — tbat  is,  about  1^  inclins.  8,30 
p.iD.,  patieat  delivered  of  twins,  living,  both  males,  Mucb 
hfflmorrhage.  Much  liquor  amiiii.  After  delivery  tbe 
cedema  rapidly  subsided. 

30th. — An  attack  of  dinrrhoeB. 

June  6lb. — Pfttieut  jesterdaj  and  to-day  complaining 
of  headache  and  loss  of  appetite. 

8th. — Urine  again  contftius  as  much  albumen  sa  ou 
admission ;  no  casts.  Headache  gone.  Appetite  had. 
Liver  dniness  to  fifth  rib  above,  to  costal  margin  below. 
Splenic  dulnesB  not  larger  than  four  fingers'  breadths. 

lOtL. — The  urine  contains  a  good  deal  of  pus,  although 
the  catheter  has  been  but  seldom  used. 

Mth. — Patient  gaining  strength  rapidly.  Is  now 
allowed  up  for  six  hours  daily.  No  pain.  No  cedema. 
Takes  food  well  and  sleeps  well.  Children  healthy  and 
strong. 

22i)d. — Patient  allowed  up  all  day^and  to  go  into  garden. 

'28lh. — Discharged. 

The  alterations  in  the  patient's  diet  are  sLowo  in  the 
ch&ri. 

I  have  cndoavourod  to  trace  the  subsequent  history  of 
tiiis  patient,  but  have  failed  to  do  so. 

Temperature. — This  was  normal  on  admission,  and  con- 
tinued so  until  the  fourth  day  of  the  lying-in,  when  it  rose 
to  1 01'2°.  It  fluctuated  between  this  level  and  the  normal 
during  the  next  eleven  days,  but  no  causo  was  discovered 
for  this  excepting  an  attack  of  diarrhoea  which  accom- 
panied the  first  rise  of  temperature.  During  the  last  five 
days  of  this  period  there  was  a  return  of  the  albuminuria, 
AS  will  be  snbsequently  described.  After  this  date  the 
temperature  did  not  exceed  1)9'6°. 

Urine. — Instructions  were  given  that  all  the  arine 
passed  by  the  patient  should  be  saved.  As  far  as  pos- 
Bible  this  was  done,  though  some  was  of  coarse  tost  when 
the  bowels  acted.  The  patient  was  allowed  to  pass  it 
herself  as  a  rale>  but  at  intervals  some  was  withdrawn  by 


innninwiifli 

wssamn 


DiBi  ■■■■■■nniiinBi 


I 


PBIOSAITOT  WITH   BRIQBT  8   DI9EABB. 


831 


tfao  catheter  to  make  sure  that  tho  characters  of  the  arino 
were  not  materially  altered  by  admixture  with  lochia. 
The  numhsr  t>i  motionB  is  shown  on  the  chart,  so  that 
the  amount  of  error  from  this  cause  can  be  roughly  estt- 
matod. 

Quantify  .—Until  delirory  the  quantity  of  nrine  was 
below  the  average,  but  under  the  influence  of  rest  and 
inilk-diet  was  increasing  slightly  ;  22  02.,  24  on.,  and 
28  oz.  are  the  amount;^  For  the  three  consecotiTe  days,  on 
the  last  of  which  the  pntienb  was  delivered.  Delivery  was 
followed  by  great  diureaia,  118  oz.  of  urine  being  passed 
in  the  twenty-four  houra  following  delivery.  During  the 
next  two  days  the  qnantity  of  Qrin.o  was  atill  more  above 
tho  avorngo,  136  oz.  and  130  oz.  being  collected.  Then 
oomM  apparently  a  auddon  drop  to  56  oz. ;  but  as  on 
thifi  day  the  bowels  acted  6ve  times,  it  ie  probable  that 
had  it  been  possible  to  onllect  all  the  urine,  the  dimiiiution 
would  not  hare  been  bo  great.  I  think  there  would  have 
been  a  diminatioD,  for  on  the  next  day,  the  BEth  of  the 
Jying-in,  all  the  urine  wa«  collected,  and  amoauted  to  80 
oz.  After  this  the  quantities  of  urine  collected  each  day 
do  not  depart  widely  from  the  normal.  They  are  on  the 
whole  rather  below  it,  but  this  is  on  some  days  accouDted 
for  by  loss  accompanying  tbo  action  of  the  bowels. 

Specific  gravity. — ^Tho  specific  gravity  varied  as  a  rule 
inversely  with  the  quantity  of  urine.  Before  doli\"ory  it 
WM  1024,  1031,  1026,  and  with  the  great  diuresis  which 
followed  delivery  it  fell  to  1012  and  1011.  Further  com- 
ment will  be  rando  in  connection  with  the  urea  percentage. 

AJhumen. — On  admission  the  urine  contained  four-fifths 
of  ite  bulk  of  albumen,  and  during  the  two  days  preceding 
delivery  became  solid  when  the  albumen  was  precipitated. 
On  the  day  following  delivery  the  albumen  dropped  to  a 
mere  trace.  On  the  tenth  day  after  delivery  the  quantity 
of  albumen  increased,  and  on  the  eleventh  day  the  urine 
again  contained  four-fifths  of  its  bulk  of  albumen.  This 
continued  for  four  days,  and  then  the  qnantity  of  albumen 
Again  began  to  diminish,  and  by  the  twentieth  day  after 


332 


PREQKAKCT   WITB   BRIOHT'8  DtSEXSB. 


(3flivi>ry  tliere  was  again  only  n  trace  of  albumeii  present, 
Tliere  was  no  accompanj'ing'  change  in  tlie  patieul'a  con- 
dition or  circnmstiLtices  which  appeared  sofficient  to  explain 
tins  temporary  increase  of  albumiouriH. 

On  May  26th,  when  precipitation  of  the  nlbumen 
rendered  the  nrine  nearly  Bolid,  the  para^lobuHn  was  pre- 
cipitated  with  sulphate  of  magnesia..  After  subsidence  tt 
occupied  about  three-eighths  of  the  tcst^tabc-  After 
eeparation  by  filtrntion  of  the  paraglobolin  the  seram 
albumen  precipitated  amounted  to  about  half  the  bulk  of 
urine.  May  29th  (fourth  day  after  delivery),  about  half 
the  albuminous  precipitate  was  found  to  be  paraglobulin. 
June  11th  (the  first  day  of  the  temporary  increase  of 
albuminuria  abova  raenbiooed),  aboat  iwo'thirda  of  tbe 
albuminous  precipitate  was  found  to  consist  of  pai-aglobulin. 
Urea. — The  amount  of  nrea  was  estimated  by  tho 
RuBsell  and  West  hypobromate  process.  In  order  to  uttain 
tho  most  acouratc  results  possible,  tbe  same  specimen  waa^ 
sometimes  tested  both  by  the  RusbcII  and  West  process 
and  by  the  Liebig  process.  The  results  of  this  complk- 
rison  may  be  interesting. 


Thti  «iliin[LLc  wu  nut  madtt 
till  two  dajH  Mftpr  ex«mi- 
iiatimiVjytlin  ItiiMcll-Wn»t 
procoss,  &Dd  tha  nriae  hod 
bcgnn  to  decompuee. 


The  corvc  indicating  the  percentage  of  urea  followa,  in 
the  direction  of  its  variations,  that  of  the  specific  gravity. 
But  before  deUrery,  the  urea-percentage  was  below  whai 
would  have  been  expected  from  the  specihc  gravity  of  the 
uriue,  while  after  debvery  it  was  higher.  On  admission 
the  percentage  of  urea  closely  ccrreaponded  to  the  specific 
gravity,  tho  latter  being  1024,  the  former  2'2.  Chi  the 
following  day,  though  the  specific  gravity  hod  risen  to 


DaOa. 

BDuell-VeiL 

UtMf. 

Jane  3 

S5S 

309-5 

..    * 

360 

342'9 

..    8 

3ia 

i'JS 

»io 

676 

MB. 

rRlOHASCT   WITH    BBIOHT'f  DlBtASB. 


833 


1029,  tlie  urea-percentage  was  only  1-6.  Ou  the  tlay  of 
delivery,  witli  ft  specific  grairifcy  of  102(3,  the  urea-peroent- 
Rge  Itad  further  ileclineil  to  I'o.  Then  comes  delircry, 
and  with  it  a  rise  in  the  percentnga  of  urea.  The  118  oz. 
of  nrine  passed  ia  the  dfty  following  delivery,  showad 
1012  specific  gravity  R-nd  1-45  per  cent,  of  urea.  During 
the  next  three  daye,  the  percentage  more  closely  ap- 
proached the  specific  gravity,  as  the  following  figares 
show : — 


Sp,  ir. 

UrFi-iMrreBUgS' 

taid»j 

<■« 

1011 

IS 

Srd  .1 

t*a 

lOU 

la 

Ml  .. 

... 

1018 

i-i 

bcgina  to 

rise 

again : — 

Up.  V- 

Umi-pcrraitt|D. 

6tlL  tUj 

1011 

1-3 

eu)  ,. 

1012 

l-3( 

m  ,. 

1018 

1-0 

8til  „ 

lOSl 

8-6 

Ml    H 

i«r 

a-6 

The  rise  in  the  specific  gravity  and  in  the  percentage  of 
urea  followed  the  addition  of  cgj^st  to  the  milk  diet.  The 
temporary  return  of  the  albuminuria,  which  has  hocn 
rcUtcd,  was  accompanied  by  still  more  transient  depres- 
sion of  the  specific  gravity  and  iirea-perccntngo.  On  the 
second  day  that  the  urine  was  again  Inarlod  with  albumen 
the  specific  gravity  was  (024,  the  percentage  of  oren  2'7. 
The  specific  gravity  and  urea-percentage  had  risen  to  their 
former  standard  before  the  albuiuiouria  had  notably 
diminliheil. 

The  total  qnantity  of  urea  was  on  the  day  of  adiniKsion 
little  below  the  average  of  health.  On  the  two  following 
days  it  sank  to  180  and  245  grains  respectively.  After 
dolivory  it  suddenly  ran  up  to  over  800  grains.  After 
this  the  quantity  gradually  declined  till  it  approached  the 
average  of  beolth.  The  temporary  incronse  in  albumin- 
uria was  proccdcd  accompanied  with  slight  depression  of 


834 


PKEONANCT    WITH    BRlGHt's    DIBEISI. 


tlie  daily  quantity  of  urea.  After  this  had  subsided,  the 
daily  urea  excretion  sgaiu  ran  up  to  over  500  graina. 
About;  the  end  of  the  second  week  of  lying-in  cy&titig 
CAQie  on,  Siud  the  nrine  soon  became  smmoniacal.  The 
diminution  in  the  amount  of  urea  which  the  chart  shows 
at  the  end  of  the  third  week  of  Ijingf-in  is  partly  aooouDtod 
for  by  decompoeition. 

Deposit. — On  admission  the  clinical  clerk  found  some 
hyaline  and  granular  casts  in  the  urine.  How  many  is 
not  recorded.  On  snbseqiieut  examinationB  very  few  or 
no  casts  were  found.  Dr.  Turner  examined  carefully  the 
urine  passed  on  May  26thj  but  only  succeeded  in  finding 
one  hyaline  cast.  On  June  6th  two  casts  were  seen  : 
none  between  these  dates,  although  sought  for.  None 
were  found  again  till  Juno  27th,  when  two  hyaline  casta 
were  present  on  the  slide. 

The  urine  did  not  at  any  time  contain  sugar. 

This  case  seems  to  me  of  much  interest  from  the  marked 
effect  which  followed  the  lessening  of  the  intra-abdominal 
pressure  produced  by  the  expulsion  of  the  abnormally 
great  uterine  contents.  During  the  three  days  wh.ioh 
followed  delivery,  the  quantity  of  nrine,  as  compared  with 
the  three  days  immediately  preceding  delivery,  was  qaio- 
tupled,  and  the  excretion  of  urea  tripled.  After  this  the 
quantity  of  urine  and  urea  gradually  fell  to  the  average  of 
health.  Diuresis  after  delivery  has  been  described  as  a 
feature  of  normal  lying-in,  but  not  to  this  extent.  It  seems 
as  if  the  abnormal  proBBure  had  hindered  the  kidneys  in 
their  work,  and  that  after  the  removal  of  this  pressure  tha 
kidneys,  so  to  speak,  tirstr  exerted  themselves  to  clear  oft 
arrftara,  and  then  returned  to  their  ordinary  functional 
activity. 

The  same  sadden  diminution  in  albuminuria  as  has  been 
observed  in  many  other  cases,  was  observed  here.  The 
albumen  was  largely  paraglobulin,  a  fact  which  supports 
the  views  of  llalfe  and  of  Magnire  that  it  is  this  form  o£ 
albumen  which  is  abundant  when  albumianria  is  due  to 
increased  pressure. 


P810NAMCT    WITH    BKJQHt's    DISEASE. 


335 


I  may  also  call  attention  inciJeutallj  to  a  minor  point, 
vis.,  tlie  effect  of  separating  the  membranes  in  stimulating 
ut«rine  action. 


Casi  3. — Surteentk  pregnancy ;  jfiis  after  confiijemenl 
tia  yeara  previously;  symptoms  at  beginniyig  of  eighth 
month  of  jircj/nanct/ ;  intra-uterine  death  of  fcetus  ;  prema- 
ture labour  induced  at  end  of  eighth  rmyiith^  after  one  week's 
treatment  bjf  rett  and  milk  diet  ;  no  diminution  in  quantity 
of  urine,  bvt  dimivished  urea-eliminat-ioti ;  albtiminuria  ; 
ditninution  of  albuminuria  and  partial  reMoratiun  of  nrea- 
excretion  hufore  deliver>f,  and  continuincf  after  delivery; 
recovery,  but  persistence  of  renal  disease  (reported  by  Dr. 
H.  G.  Ly»,  Resident  Accoucheurj  and  Mr.  F.  S.  Harris, 
Clinical  Clerk). 

A.  G—,  aged  36,  admitted  March   lUli,   1889. 

Patient  ia  a  Polish  Jewess.  81ie  came  to  hoapital  on 
account  of  enelling  of  face  and  legs.  Said  sho  had  had 
DO  illnees  except  in  connection  with  pregnancies.  Came  to 
Eogland  at  the  ago  of  twenty-two,  and  had  since  then  lived 
in  the  East-end  of  London  and  worked  as  a  tailor&gs.  Had 
Qocasionally  been  so  badly  oEf  as  not  to  get  enough  to  eat; 
Qsoally  worked  twelve  hours  a  day. 

First  meDBtrnated  at  sixteen.  Catameniuregntar,  except 
during  pregnancy,  and  generally  without  pain.  Was 
married  at  twenty-two,  and  has  had  fifteen  pregnancies. 
Five  cndediu delivery  o£  living  children  at  or  near  term,and 
ten  in  miscarriages  at  about  three  months.  8ix  yeara 
ago,  after  a  conliiieraont,  she  was  very  ill  with  "  fits." 
Now  thinks  herself  eight  months  pregnant.  Until  throo 
WMkfl  ago  felt  the  child'A  movemeuts.  Throe  weeks  ago 
her  face  and  legs  began  to  ewcH,  tbo  eyelids  first.  For 
the  same  time  she  bn^  suffered  from  severe  and  constant 
headache,  has  slept  badly,  and  had  a  cough.  Has  only 
vomited  once.      Has  pa-is^ed  much  urine. 

On  admission  the  urine  was  clear,  free  from  deposit, 
sp.  gr.  1018,  and  containbg  one-fifth  albamou.  Patient 
was  put  OQ  milk  diet. 


383 


PBtSKAVCT   WITET  BBIOEl'S   DlBEAfi&l 


March  loth. — The  following  note  was  made  : — PaU 
is  somBtvliataQiBniic  ;  faCe  puSy.      C&rdiac  dulaeaBnwl 
on  the  right  to  tbd  middle  line,  od  tho  loft  to  a  fingdr* 
breadtli  beyond  the  nipple  ;  no  nnirmnp.      Slight  oodem 
of  feet.      Arteries  very  hard.      Fundua  ut^ri  reaches  no 
quite  halfway  between  umbilious  and  ensifnrm  cartilage. 
Cervical    canal    not  admitting   finger.      Cervir  TiaB  been 
deeply  lacerated  to  left. 

17th.— A  flexible  bongio  was  introduced  into  the  uterus 
for  its  whole  length,  and  left  there. 

18th. — Patient  delivered  about  midday  of  Adecoroposing 
(cetus.  Presentation  by  the  breech.  Delivery  of  the  head 
vaa  aeeisted  by  tractiou.      No  excessive  baQniorrhage. 

15th. — Ophthalmoscopic  examination  shows  neuro- 
rctinitie  and  white  patches  in  both  retiniD, 

April  3rd. — Patient  put  on  fish  diet. 

8th. — Discharged.  Feols  quite  well.  No  oedema. 
Appetite  good.  Sleeps  well.  Trace  of  albumen  still 
pi-esent. 

Temperature. — This  calls  for  no  especial  remark,  as  (fc 
never  exceeded  100°. 

Urine. — Inatractioas  were  given  that  all  the  urine  passed 
by  the  patient  should  be  collected  and  measured. 

Quantittf, — Taking  into  consideration  that  some  urine 
was  lost  with  the  iDotions,  the  quantity  of  urine  waa 
slightly  above  that  which  is  nsually  regarded,  as  the  average 
of  health.  The  amount  averaged  43  07..  per  day  before 
delivery,  42  oz.  per  day  after.  The  boweU  acted  on  the 
average  once  a  day  before  delivery,  about  three  times  in 
two  days  afterwards.  On  the  day  of  delivery  the  amoimt 
collected  was  larger  than  on  the  days  immediately  pr 
ceding  and  following,  which  looks  as  if  some  diuresia 
followed  delivery.  But,  on  the  whole,  the  variations  in 
the  quantity  of  urine  do  not  seem  large  enough  to  ba 
important. 

Specific  gravity. — Thia  ranged  from  1012  to  1020.  I 
shall  refer  to  its  variations  in  connection  with  tha  per> 
coutage  of  urea. 


SS8 


PBBOH&KCT    WITH    BBIORT  8   IJI8KASB. 


Alhumev. — On  admission  the  uriae  contained  one-fifth 
of  its  bulk  of  albumen.  The  amount  nt  albumen  began 
to  diujiuisli  after  five  days'  treatment  by  rest  and  milk 
diet,  and  before  delivery  bad  tdkeu  place.  After  delivery 
the  diminution  continued,  and  iu  a  week  had  sunk  to  a 
trace.  Throughout  the  rest  of  the  patient's  stay  in  hos- 
pital the  ui-ine  contained  either  only  a  trace  of  aLbumcu 
or  none  at  all. 

The  relative  amounts  of  serDm-albumen  and  para> 
globulin  were  unfortunately  not  ascertained. 

Urea. — The  percentage  of  urea  on  admission  was  below 
that  which  would  have  been  expected  from  the  specific 
gravity  of  the  urine,  the  former  being  '9,  the  latter  1012. 
Daring  the  five  days  preceding  delivery  the  BpeciBc 
gravity  of  the  urine  diminished  ;  bnt  during  the  last  two 
of  these  days  the  percentage  ot  nrea  increased.  After 
delivery  thn  perceutagc  of  urea  still  further  increased, 
reaching  its  maximum  (I'G  per  cent.)  on  the  sixth  day. 
After  delivery  the  percentage  of  urea  carve  shows  a 
rough  correspondence  with  the  specific  gravity  curre, 
which  it  did  not  before.  The  increaac  in  the  percentage  of 
urea  distinctly  coincidoa  with  diminution  in  the  amount  of 
ulbamen.  Thetotal  nroa-cscrett on  shows  a  marked  incraaso 
after  delivery  as  compared  with  tliat  before  delivery, 
although  the  patient's  diet  was  unchanged.  Tlie  urea 
eliminated  before  delivery  averaged  156  grains  per  day. 
After  delivery  it  averaged  269  grains  daily ;  althongh,  as 
has  been  mentioned,  more  was  probably  lost  with  the 
motions  than  before  delivery.  There  was  no  deposit  from 
the  urine.  Casts  were  not  found.  They  were  looked  for, 
bat  I  am  unable  to  say  how  often.  The  urine  at  no  time 
contained  sugar. 

November  I9th,  1889. — Four  weeks  ago  patient  had 
what  she  thinks  wn.s  a  mtscarrifige.  Says  that  she  fcoU 
very  weak,  and  that  her  head  soems  confused.  Three 
months  ago  she  hbd  what  she  calls  "con^Tilsion  fits;" 
this  statement  her  friend  who  is  with  her  confirms,  and 
says  tbey  were  attributed  to  indigestion;  but  neither  can 


PRKOWANCT   WITH    BBIDHT*B  niSKASr. 


3M 


give  a  very  clear  ncoount  of  the  fits.  Has  had  no  vomit- 
ing. There  is  nlight  cedema  of  right  leg,  none  of  face. 
Appetite  moderate.  She  is  anfemic.  Arteries  very  hard, 
RetinsB  show  spots  and  patches,  the  results  of  old  liBetnor- 
phttge.  Uriue  (drswn  with  catheter)  sp.  gr.  1009,  contains 
OQe*tentKoE  alliiimen,  mainly  serum-albutnon,  only  a  traco 
of  paroglobnlin. 

December,  1890. — Urine  contains  {  albamen,  and  gives 
a  depofiit  containing  pns-cells,  and  a  few  epithelial  casts. 

This  case  difEors  from  that  which  precedes  it  in  somo 
important  particulars.  There  was  not  such  great  abdominal 
distoneionj  the  uteras  being  rather  amaller  than  would  havo 
been  expected  from  the  patient'H  account  of  hor  period  of 
pregnancy.  There  was  no  marked  diminution  in  the 
amount  of  urine  before  delivery,  nor  marked  diuresis  after; 
and  the  change  in  the  amount  of  urea  eliminated  was  not 
80  great.  Unlike  the  other  three  cases  recorded  in  this 
paper,  and  unlike  meet  coses  of  ecIampsiBj  the  urine, 
instead  of  being  almost  solid  with  albumen,  only  contained 
about  onc-fifth.  As  in  other  cases,  the  effect  of  treatment 
by  rest  and  milk  diet  n-as  to  diminish  the  amount  of  th^ 
albuminuria,  and  the  effect  of  delivery  to  dimiuish  it 
stiti  further. 

The  urea-excretion  was  much  below  the  average  when 
the  patient  was  admitted  ;  it  rose  under  treatment  by  rest 
and  milk  diet,  and  still  further  rose  after  delivery  ;  h\^b 
throughout  it  was  below  what  is  regarded  as  the  average 
of  health. 

I  may  point  nut  aleo  that  the  symptoms  in  pregnancy 
were  more  marked  than  in  the  other  casea,  and  that  the 
disease  persisted  nearly  two  years  afterwards. 


The  reading  of  the  fourth  case  wa«  adjourned  nntil  tho 
following  meeting. 


NOVEMBER  5ib,  18D0. 

Alpked  h.  Ualabin,  M.D.,  Frosideat>  in  the  Chair. 

Present — 4!  Fellows  and  3  Visitors. 

W.  U.  Laarence  Copeland^  M.B.Cantab. ;  HaroM  Low, 
M.B.Cantab. ;  Frederick  Johu  McCauii,  M.B.,  C.M.Ediu. ; 
Harold  Burgcsii  Osbura,  I/.B.C.P. ;  Samuol  W.  Wbeaton, 
M.D.Lond. ;  and  R.  Muzio  WilliamSj  M.D.Lond.j  were 
udmittrcd  Fellown  of  tVe  Boctcty. 

Richard  Ackerley,  M.B.,  B.S.Oxon.  (Asbbiirton] ;  !D«vid 
Berry  Hart,  M.D.Edin.  (Edinbnrgh} ;  Charles  David 
Green,  M.D.Loud.  (Upper  Edmonton] ;  John  William 
Taylor,  P.R.C.S.  (BinninghBm)  ;  and  Kdwiu  Francis 
White,  F.U.C.S.  (Patney),  were  declared  admitted. 

The  following  gentlemen  were  elected  Fellows  oE  ibo 
Society  : — John  Dysart  McCaw,  F.R.C.S.  (East  Finehluy)  ; 
Hagh  Jones  Roberts,  M.R.C.S.  (Peuygroeij) ;  aud  Ueory 
Bartlctt  Shillingford,  L.S.A. 

The  following  gentlemen  were  proposed  for  election  . — 
Thomait  S.  Allan,  L.R.C.F.  and  S.Ed.  (Tonbridge)  ; 
Skene  Keith,  M.B.,  C.M.Edic.  ;  Kdgar  Ashley  Lubbock, 
L.R.C.P.Lond. ;  John  Reynolds,  M.D.Brox. ;  aud  Frederick 
Sloman,  M.R.C.S.  (Brighton). 


542 


5E  OP  TUBAL  ABORTION. 


By  J.  BiAND  SurroN. 

In  Mny,  1890,  I  saw  in  cousaltation  with  Dr.  Clegg,  of 
Htratford,  Mrs.  N — ,  aged  26  years,  tlie  mother  of  two 
cbildreiij  the  youngest  being  six  yeRrs  «ld, 

The  patient  complained  of  great  pain  in  the  lower  park 
uf  the  abdomen.  The  pain  commenced  enddeutj  three 
days  before  I  ttaw  her,  and  was  acouinpaniod  by  a  fruo 
disoharge  of  blood  from  the  uterns.  Thu  cutamenia  had 
been  quite  regular  during  the  last  four  years. 

On  examining  the  abdomon  no  swelling  could  be  de- 
tected. The  left  breast  was  slighWy  enlarged,  and  milk 
could  be  easily  squeezed  from  it.  There  was  no  difficulty 
with  the  bladder.  On  examining  the  pelvic  viscera  a 
rounded,  moveable,  tender  swelKiig  could  bo  niiide  out  on 
the  left  side  of  the  uteruSj  and  a  similar  but  larger  Gwelling 
on  the  right  side,  but  this  was  not  tender.  The  patient 
was  admitted  to  the  hospital  next  day,  and  Dr.  Boxall 
kindly  saw  the  case  with  me.  He  suspected  that  it  was 
a  retroflexed  gravid  uterua.  Iq  order  to  settle  the  dia- 
gnosis chloroform  was  a-dminiateredj  and  Dr.  Boxall 
pushed  the  swelling  on  the  left  side  upwards  into  the 
abdomen.  It  was  than  found  to  be  distinct  from  the 
uterus,  which  was  clearly  not  gravid.  In  the  afternoon 
the  patient  complained  of  severe  aching  pain  in  the  back, 
and  had  a  very  thin  pulse,  and  at  6  o'clock  the  tempera- 
ture rose  to  103°.  It  was  clear  that  some  mischief  bad 
been  done  to  the  tumour.  Next  day  I  opened  the  abdo- 
men  and  found  the  intestines  swimming  in  blood.  I 
aeiaed  the  left  Fallopian  tube  and  drew  it  upwards.  It 
was  enlarged,  tho  OBtium  widely  diluted,  and  coutained 
olots  of  blood.  It  was  trausOxed  with  silk,  tied,  and 
removed.      On  examining  the  right  side  an  ovarian  oy&t 


TUBAL  AUORTIOK. 


345 


of  the  size  of  a  targe  orange  was  found  and  removed  in 
the  usual  way.  The  blood  iu  the  peritutieal  cavity  was 
now  washed  ont  by  means  of  water  ab  105°,  a.ad  the  wound 
c'losud.  On  the  evening-  following  the  operation  the  tcin- 
porutura  rose  to  102*,  tht-u  slowly  tell  to  normal  ;  cou- 
valescenco  was  uninterrupted,  and  patient  left  the  hoepitul 
fourteen  days  after  the  operation. 

On  examining  the  parts  removed  at  tie  oporation  I 
found  the  right  ovary  occupied  "by  an  "  oophoritic  *'  eyst 
(Fig.  I),  cootatiitDg  fluid  largely  charged  with  cholesteriuo. 


AecciIOflY  OSTIUM 


-TUBE 


OSTIVM- 


PABOVAff  tUM  - 


j-V 


-^ 


Fii>>  1.— OvBriAn  eytt  o(  the  ri|;Iit  tide  with  an  nccMtory  oitinin 
b<  tliv  tub«.     (CW  of  Mr».  N— .) 


The  Pallopi&a  tttbo,  &s  shown  io  the  drawing,  presented 
an  accessory  ostium,  a  not  infrequent  anomaly.  The  nto- 
hno  portion  of  this  tube  was  uuuijually  narrow,  tbe  corre- 


S44  TUBAL   ABOKTIOK. 

Bpotding  portion  of  the  left  tube  was  also  very  nnrrow, 
bat  its  ampulla  was  congested  and  dilated  to  llio  thick- 
ness of  the  tlitinib.  Its  oBtium  whb  wide  and  patent.  A 
rounded  firm  body  as  large  as  the  kenie!  of  a  cob-nut  was 
felt  within  the  tube.  Ou  slittiug  up  tlietnbp,  this  rounded 
body  was  adherent  by  a  small  portion  of  itscircamference 
to  the  tubal  inacouB  membrane.  The  free  portion  of  thia 
body  presented  numerous  small  villous  processes  ;  its  iotc- 


CHOMflHK   V|L 

TUBE    '•^^    t^^t^J^,    //( 


M>DPIBGTIC    BVU"! 


\^i 


Fie.  2. — The  left  tube  of  Mrs.  N —  opened  to  expose  the  it^pleetie  ovuw. 

riorwaa  occupied  by  a  small  rounded  cfLvity  which  contained 
fluid,  and  the  walls  were  lined  by  a  delicate  membrane. 
Portione  of  the  wall  were  removed,  hardenedj  and  esamtned 
with  the  microacope.  The  sections  consisted  of  blood- 
clot,  mingled  with  chorionic  villi.  Thus  the  raaorosoopic 
uud  microscopic  characters   showed  clearly  enough  that 


l^OBAL    AfiOBTIOH. 


345 


this  ronndod  body  was  what  is  called  hy  obHtetrtciiLtiK  an 
"apoplectic  ovutu."  The  term  signifies  an  orum  in  which 
blood  has  been  extravasated  icto  its  membranes  and 
chorion. 

The  mucouN  membrane  iu  the  adjacent  parts  oF  the 
tube  still  retained  its  epitheHum.  The  cori'esponding 
Qvarj  waa  enlarged,  cVHtic,  and  contained  a  recent  corpus 
luternn.  The  diaaectiou  of  the  parte  cleai-ed  up  the  nature 
of  the  case.  Thia  woman  had  an  impregnated  ovum  re- 
tained in  tho  loft  Fallopian  tubo.  At  the  time  she  was 
seized  with  sudden  pnin,  the  ovum  had  become  partially 
detnehod  and  tbe  tubo  distended  with  blood.  When  this 
tube  was  pushed  out  of  tba  pelvis  fresh  liafinitrrhago  was 
caused,  probably  through  further  dutachnieiitof  the  ovum 


m- 


'^\ 


< 


■*^ 


'^; 


PlO.  >■ — ^Th«  ovaa  im  Mm.    IU  nfttnnl  ilw  \»  >howa  in  Elg  i. 


from  the  tubal  mucous  membrane.     This  is  the  third  time 
in  which  I  have  found  aa  apoplectic  orum  in  cose&of  tubal 


d46 


OVJlR¥    and    TtJBK    WITH    CAPILLOKA. 


pregnancy  among  tho  examples  oE  ectopic  gestation  OD 
which  I  have  been  called  upon  to  operate. 

I  first  called  attention  toibe  formation  of  an  apoplectic 
ovum  in  tuba!  pregnaQcies  iu  1889.  Recently  Karl  Kt?ller 
and  Ortlimanu  liave  publishod  in  '  ZeltscbriEt  fiir  Guburts- 
hfltfe,'  Bd.  XIX,  a  eeries  of  cases  in  wliich  the  ovom  in 
the  tube  was  converted  into  an  apoplectic  ovum,  Keller 
reported  three  cai^es,  and  Orthmann  ten ;  these  cases  con- 
firm my  observation  in  every  particular.  Keller's  paper 
is  very  interesting,  and  he  points  out  that  tubal  pregnancy 
may  bo  ai-reated  either  by  rupturu  of  the  walls  of  tho  ges- 
tation sac  or  the  expulsion  of  the  ovum  into  the  peritoneal 
cavity  through  the  abdominal  ostium  ;  this  last  he  terms  a 
tubal  aho7-tioH  in  contradiatiactiou  to  the  escape  of  the 
ovum  through  a  rent  iu  the  tube. 

In  order  to  make  the  case  as  complete  ^  possible,  a 
magnified  view  of  the  ovum  is  shown  in  Fig.  3.  Many 
of  the  aectious  were  carefully  esamiufid  in  the  hopo  of 
finding  some  traces  of  the  embryo,  but  with  a  QCgativo 
result;  it  secme  to  hiiTo  been  dcstroyod  by  tho  hasmor- 
rbage. 

Dr.  Gbiffitu  staled  an  liia  opiuiuu  that  hcetuorrliago  into  the 
cboriou  was  found  in  vnryiug  degreoa  in  every  vane  of  oitm- 
uterine  gestation  iu  wht<r(i  rupture  had  taken  pl^e,  aod  that 
wliilat  liieiiiiorrliage  miglit  in  Bome  cases  be  tlie  L-ause  of  rupture, 
it  WBB  undoubtedly  more  often  the  result. 


SUPPURATING    DERMOID    CYST. 
By  W.  Ddkcan,  M.D. 


OVARY    AND   TUBE    WITH    PAPILLOMA. 
By  W.  DuMUAH,  M.D. 


847 


CASE   OP  ACEPHALOUS  ACARDIAC  TWIN. 
By  Amakd  RoDiB,  M.D.,  B.8. 

Tois  specimcD  of  accplmlous  acardiac  twin  was  pro- 
Hvutod  to  Ctiaritig  Cross  Uuspitnl  sotno  months  ago  by 
Dr.  Gibson  Berkley,  "who  acted  as  accoacLour  at  its  birth. 

It  had  remained  in  spirit  till  iafit  week,  when  Dr. 
Lubboclc,  the  curator  of  the  raosenm,  asked  me  to  write  a 
description  of  it  for  the  cntnlogiie.  It  is  by  these  gen- 
tlemen's kind  pennifision  that  I  am  allowed  to  show  it  to- 
uight. 

Dr.  Gibttoa  Berkley  states  that  it  was  uue  of  twins, 
both  fciiiulu,  and  tliiuks  (though  aa  interval  of  some 
monthn  has  olapncd)  that  there  were  two  distinct  placeutce 
and  cord^. 

The  womau  was  a  mullipara,  aud  lliu  aciirdiac  twiu  was 
born  first.  The  normal  twiu  was  but  ono-tbird  of  the 
proper  size,  and  lived  only  three  days. 

Tbu  s})ecimen  is  a  ^oud  sample  of  the  acephalous  variety 
of  fcetna  acardincus,  marked  by  arrented  development  uf 
tho  viscera  and  extreme  oedema  of  the  enbcutaneous 
oounectivo  tissue. 

The  external  genitals  are  tbose  of  a  female,  and  the 
lower  part  of  the  vagina  is  patent.  The  unas  is  aUo 
present,  and  the  ri>otum  is  patent  throughout. 

The  difBcnlty  in  dissecting  such  a  specimen  ae  this, 
wbick  had  been  imtnereed  in  spirit  for  a  year^  was  great, 
and  I  was  very  glad  to  avail  myself  of  the  gi-cater  expe- 
rience of  McBsrs.  Bland  Suttou,  Alban  Doran,  and  Dr.  W. 
S.  A.  Griffith.  The  first  very  kindly  enabled  mo  to  identify 
many  of  the  points  of  interest. 

There  appears  to  be  no  trace  of  the  head.  The  upper 
limbs  are  represented  by  the  clavicles,  and  a.  nodule  of  bone 
which  appears  to  be  the  head  of  a  left  humerus.     The 


846 


ACKPHALODB    ACABDUC    TWIN. 


Hpinal  coIiitiiH,  sacrum,  and  ribs  are  present,  and  the 
sternum  ia  represented  hy  an  irregular  tnasB  of  cartilage. 
TLe  pelvia  and  leg  bonea  are  fairly  well  developed. 

All  umbilical  Iiernia  protrudes  nttlie  navel,  and  the  cord 
is  seen  on  its  right.  By  making  vertical  iuci&ions  through  ' 
the  oDdematouB  tissue  in  tbo  two  nipplc-lincs  and  rofloct- 
ing  the  intervening  integument  tipwards  from  the  pubic 
arch,  L'oila  of  iiitestiuo  are  soon  and  can  bo  traced  upwards 
to  the  hernia  aud  downwards  to  the  rectum. 

On  eitlier  side,  leyel  with  the  brim  of  the  pelviii,  is  a 
genital  gland,  presumably  an  ovary.  The  vagina  appears 
to  end  in  a  cut-de-sac.  No  uterus  is  distinctly  seen.  The 
bladder,  with  a  patent  nrachns,  in  tamed  np  with  the 
reflected  intcguuient.  Two  lobulated  kidneys,  lying  iu 
contact  iu  the  middle  line,  are  very  dititinot,  and  ono 
ureter  can  be  traced  down  to  the  true  pelvis,  There  ia 
a  Eomewhat  creeccnt-shaped  body  lying  above  the  kidneys 
behind  the  ribs,  which  is  poseibly  the  heart,  and  a  vessel 
representing  the  aorta  ean  be  followed  downwards. 

Behind  and  outside  this  visceral  space  are  two  largft' 
spaces  with  a  membranous  lining,  containing  a  subatanee 
which  rosemblea  the  tissue  of  tho  choroid  plexus  of  the 
lateral  ventricle  of  the  brain  ;  but  the  position  of  the 
spacee,  posterior  to  the  neural  arch,  point  more  to  acci- 
dental cysts  than  to  any  developmental  significance. 

Mr.  AiBAlt  I>oRA.>'  could  not  feel  Botisfied  that  a  rudiineatary 
heart  eiistcd.  A  trace  of  a  heart  waa  usually  seen  in  acardiacus 
paracephalu?,  where  rudiniC'Dts  of  the  Lead  were  pretout.  This 
condition  wae  figured  iu  his  own  Bkeitcl)  of  tho  (pecimen  in  fit. 
George'H  HuHpital  Aluseijm,  which  accompanied  hie  ootea  OD  Hr. 
Treatrail'B  B[]ef.-imeii  of  niyUi-epbalous  acardtac  twin  in  vol.  xizi 
of  the  Socifty's  'Tranaactioiift.' 

The  specimen  waa  referred  to  a  committee  consisting  of 
Dr.  Amaod  Routh^  Mr.  Bland  Suttou,  and  Mr.  Domu. 


349 


FOUR  CASES  OP  PaBGNANOY  WITH   BRIGHT'S 
DISB.A8B. 

BjrO.  Kkkest  Hermak,  M.B.Lond.,  P.R.C.P., 

OUTBTilC  fllTtlCIAV  TO  vau   IX)!(IiOl'  BOlPtTAU 


(Coniinued/hun  ^age  3»1^.) 

Ci9E  4.  Albuminuria ;  wrffmir  f.witehinga ;  et^ebral 
hfcmorrhage ;  induetion  of  labour  at  beginning  of  eighth 
month;  (kild  living;  diminished  urea-elimination  before 
Heliverif  ;  after  deliwnj  rapid  inereanp  in  pprcentage  of 
vrea  and  tanjiorarg  divUntUloji  of  albuminuria  ;  reneiecd 
cerebral  hieinorrhage  ;  coma  ;  death  ;  ntj  aatopny. — Tliis 
cue  in  iucumplutc  iu  maQy  re.<4pcctH,  bnt  tho  recurdH  of 
tho  urine  are  intcrciiting.  (The  notes  were  tftken  by  Mr. 
K.  A.  K*ihineon,  Clinical  Clerk,  under  tlie  superrision  of 
l>r.  W.  J.  Httdley,  Resident  Accoucheur.)  R.  B — ,  set.  41, 
admitted  into  Victor  Ward,  London  Hospital,  January 
28th,  1880.  No  prpvioua  history  could  bo  obtftinod,  the 
pntient  boiog  UDnblo  to  givo  one. 

Janonry  Slst.— Tlio  folloniDg*  note  was  made.  Patient 
iit  thfn  bat  not  anaemic.  Speech  thick  and  diiBcuIt  to 
underistand.  Slighb  bilateral  muscular  twitching^.  Puke 
har*l,  arteries  thickened.  Heart's  apex  below  sixth  rib 
and  just  internal  to  nipple;  no  murmur.  No  cedema. 
Utertia  reaches  not  qnite  hnlfway  between  ambilious  and 
ensiform  cartilage ;  fcctal  beart  audible.  Ophtbulraos- 
oopic  cxaniiaation  shows  nothing  abnormal.  Takes  food 
well.  Patient  is  undorstood  to  say  that  she  has  of  late 
bad  a  severe  headache  every  evening,  but  hao  ■ 
Has  had  vomiting  ocoasionally,  but  not 


850 


MlBONAJfCY  WITH  BBIOHT'H  DIBlAmi. 


plains  of  bad  cong'h.     No  abnormal  signs  In  lungs  other 
than  bronchial  r&les, 

In  the  afternoon  and  evening  of  this  day,  right  hemi- 
plegia with  aphasia  gradually  came  on. 

February  let,  3  p.m. — A  bougie  put  into  the  ntoms. 
9.15  p.m.j  pains  first  noticed. 

2u,d,  1.30  a.m. — Patient  delivered  naturally  oE  a  living 
child,  male.  Not  much  haemorrhage.  Ergot  gtreo  after 
delivery. 

8th. — Patient's  condition  has  gradually  improved,  para- 
lysis lessening,  speech  retapning. 

After  the  last  noto  waa  made,  coma  gradually  came  on, 
and  patient  died  on  Febmnry  10th,  at  9  a.m.  No  autopsy 
was  allowed. 

Temperature. — This  never  exceeded  ^9",  and  before 
death  became  abnormal. 

Urine.  Quantity. — It  was  only  measured  on  two  days, 
January  28ti  and  29th.  The  quantity  was  helow  normnl, 
being  \%  oz.  the  28tb  (once  lost  with  stool],  23  ok.  the 
29th  (twice  lost). 

iS^)eri/(c  gravity. — Here  the  reoord  is  also  imperfect: 
January  30t]i  and  31st  it  was  1020;  February  Jut,  1012  ; 
4th,  1030 ;  5th  and  7th,  1026 :  so  that  the  specific 
gravity  rose  after  delivery. 

Albnwen. — On  odtnisaion  the  urine  contained  half  its 
bulk  of  alhumou.  This  continued  till  February  2ud  (day 
of  delivery)  whou  it  sank  to  one-third,  and  February  3rd 
to  one-fourth.  After  this  it  increased  again,  6o  that  on 
February  5th  the  quantity  was  the  same  as  on  ndmisxion. 
Delivery  was  thus  followed  by  a  diminution  in  the  quantity 
of  albumen.  February  9th,  the  day  preceding  death,  the 
urine  was  nearly  solid  with  albumen.  On  January  29th 
and  on  February  9th  the  paraglohulin  was  separatetl  from 
the  aeram-albumen,  and  it  was  found  that  the  albumen 
was  almost  entirely  serum-albumen. 

Urea. — Before  delivery  the  percentage  of  urea  was  less 
than  the  average,  and  less  than  would  have  been  expected 
from  the  specific  gravity  oE  the  urine.      In  the  two  days 


PBMSftNCT   WITH    BBtOHT'S    DISKABR. 


351 


following  delivery  it  rose  to  more  than  double  what  it  had 
hecD,  aod  more  than  would  Lave  been  expected  from  the 
BpooiGo  gravitj.  Duriug  tlie  four  days  preceding  delivery 
it  averaged  1'3.  On  the  day  after  delivery  it  was  1-9, 
and  during  the  eix  following-  days  it  na%  3"  15.  The 
figures  follow : 


Before  delivarg. 

Jan.  29=  1-3 

„     80= W 

„    30=1-4 

Feb.    I  =1-1 

Dag  (^  delivery. 
Feb.    2=l'fi 


4/ler  JBlivefji. 
Feb.  a- 10 
..  4=31 
,.  6  =  3-6 
„  6  =  8-2 
.,  7  =  3  1 
„  8=3-5 
„    9=  80 


Deptntii. — Before  delivery,  the  unnc  contained  epithelial 
and  Fatty  casts.  I  liavo  no  noto  of  the  deposit  subse- 
qaently.     No  sugar  was  found  in  the  urine. 

I  publish  this  case  because,  like  the  others,  it  exhibits 
rapid  increase  iu  the  urea-perceiitage  following  delivery, 
and  aleo  dimiuution  in  the  albumiuuria. 

It  would  be  premature  to  generalise  as  to  the  mutual 
effects  of  pregnancy  and  Brigbt's  disBaiie  from  these  few 
oaseH.  But  the  phenomenii  upon  which  I  have  commented 
show  that  there  are  such  effects.  The  study  of  the  detaiU 
of  cases  ia  the  only  way  of  attaining  definite  knowledge  on 
this  subject,  and  therefore  I  have  thought  thi'se  cases 
worth  bringing  before  the  Society. 

Dr.  Lettk  NiPiEs  t&id  that  the  ca«eB  recorded  by  Dr.  Herman 
were  a  Taluable  nddition  to  the  knowledge  alrendy  poKsoKted 
regarding  kidney  dlneoiie  in  pre^^nancv.  DLriug  gestation  there 
was  a  specialty  unstable  eonoition  of  the  epithelial  i\»tno  in  all 
the   targe  slandF,  nnd,  as  might  be  expected,  thp  kidacys  fre- 

Suputly  sunered.  Dr.  Herman'R  ra«OH  wero  illuEtrative  of  the 
act  that  (li»tiii<?t  rpnal  dj»cABe  might  esilt  in  pregnane;  without 
any  aubBcqucnt  ccinmjjBin.  Twenty-five  jeare  ago  SevftTl,  of 
Prague,  showed  tliat.  of  ii«TentT  patients  auffering  from  kidney 
dtBCAfle  duriug  geatnlion,  only  two  developed  eclampeia.  A  mors 
recent  icrieH  of  152  caves,  in  which  autop^it-fl  were  made  on 

Ju«r[wral  and  pregnant  women  wlio  were  found  to  lutve  Bright'* 
iseaae,  sbowed  that  unlj  tl'Sper  cent,  had  eclamptic  tymptoma. 


852 


PRROlTAlfOI 


tBlOBT^S   DtaiASf. 


BtiTnbprger  in  tlint  series  included  acute  chronic  and  fttrophje  renal 
diacase.     Brn.uii>  who  hae  douv  more  tbaii  aayoii»  else  to  conmct 
iirasmia  with  eclampain,  estimated  that  GO  per  cent,  of  vomen 
suffering  fToni  acute  aud  chronic  Bright'H  disease  woald  develop 
conviilaivu».      Spiegel  berg,   who    most    warmly  espouBsd    tbo 
urermic  origin  of  eclanipBia,  admitted  that  some  catiea  could  not 
be  accounted  for  by  pre-exigtent  kidner  disease.    8oiiie  years  ago 
Dr,  Leith  Napier  had  mentioned  cases  of  chronic  kidney  diseaso 
in  pregnancy  which  were  not  asaociated  with  eclampeia.     He 
referred  to  one  very  highly  illustrative  case  in  which,  altfaough  a 
pn?gnant  woman  who  bod  contracted  scarlatina  and  thereafter 
aufi'cred  from  ^ery  well-marked  nephritis,  the  pregnancy  con- 
tinued, and  when,  eoine  months  after,  she  was  delivered,  there 
was  not  the  alightosl  interruption  lo  a  favourable  recovery.     Ho 
regarded  tlie  eetimation  of  ui-ea  and  albumen  as  of  great  import- 
ance, but  1)0  thought  we  required  furthef  iaformalion  than  w© 
yet  posHessed,  ae  to  some  points  on  which  he  would  like  to  s«k 
Dr  }lerinfln'a  opinion — What  waa  the  normal  amount  of  urea 
exi  ruted  during  pregtiuncy  ?     Viae  it  greater  or  leai  than  in  the 
nun-pregnant  ?     Dr.  Napier  believed  it  to  be  less,  and  that  there 
waa  almost  invariably  increased  elimination  after    parturition. 
As  to  albuuiiuuria,  this  oci:urred  so  very  Ire^uently  in  pregnancy 
from    well-recognised  causes,  aud   was  often   so   temporary   in 
clmracter  that,  uuloaa  we  had  other  evidences  aasoeisted,  wu  iDtist 
Qot  attach  too  great  importance  to  it.     He  thought  thatall  albu- 
niinuries.  whateverwas  the  cause, were reltevedal'ter  parturition. 
The  eiisteuee  of  acetonuria  m  relation  to  eclompRia  wan  of  tome 
impertftDce.    Le'corchi^'and  Fclilingt  i^ud  also  Dyers  hod  recently 
directed  attention  to  thiN.     Had  Dr.  Herman  made  any  observa- 
tions bearing  on  this  point? 

Dr.  C.  U.  F.  HouTH  admitted  he  was  labouring  under  tl . 
disadvantage  of  not  having  heard  detaile  of  Dr.  Herman's  Gnt'l 
two  casca,  but  he  had  lizard  the  detaila  of  the  last  two  and  read 
the  abfitracta  of  the  remainder.  He  did  not  think  that  they 
eliould  be  called  casea  of  Briglit's  diseaaB  merely  because  albu-j 
minui'ia  was  present.  It  was  well  knuwu  that  albumiDurin  oftOD 
resulted  from  the  pressure  of  tumours,  such  as  ovarian  cysts  and 
uterine  filbroide,  on  the  kidoeya.  On  the  removal  of  theee  tumoura 
the  albuminuria  disappeared.  The  same  waM  frequotiL  in  preg> 
nancy.  Now  he  believed  that  unless  caats  vern  found  in  tho 
uriue  likewise,  and  unless  by  tbo  use  of  the  ophlhaluiuseope 
eiideiicea  of  neuritis  and  local  congeation  existed  in  the  eye,  we 
had  no  right  to  diagnoHC  those  cases  us  Brigln's  disease.  He  did 
Dot  gather  that  in  any  of  these  cases,  except  the  third,  the  usual 
opIithalmoBcopic  signs  were   observed.     lu  thia  caee  the  signs 

*  '  Annnlc*  do  Qyn^iwlaglc,'  Oct.,  1880. 

t  •  Pliysiul.  a.  PutbuluKiu  dn  WiK'livubutU,'  Stuttgart,  1800,  p.  ItU. 


PEEONAJfCT   WTTB    BBIOHt's    DISBA8E. 


wore  jtrcneut  but  vaniHlitd  after  dulivL-ry.  Puerperal  coiivulsicius 
produced  by  Briglit'a  diEeaBe  were  c'H|)aI)l«  uf  being  a^rrealt'il  by 
remoral  of  the  pressure  on  the  kidneys  ;  this  fact  was  proved  by 
tbc  cessation  of  the  dta  after  delivery  to  moat  e&&ea.  Moreover, 
be  remembered  one  case  of  terrible  convuUions  occurring  every 
tea  or  |{rtci:<ii  miiiutPM,  oue  of  l)ie  wor^t  he  ever  »aw,  in  which  he 
•nut  called  in,  nod  where  in  attempting  to  deliver  bo  found  pro- 
inpse  of  the  cord.  This  he  reduced  on  Sir  JnineB  Simpeon's  plan 
by  putting  the  pftticnt  on  her  belly.  The  momont  this  was 
effected  the  convulaions  stopped  and  did  not  recur.  It  was  to  be 
iiiuleretood  hair  even  iu  h  case  of  Bright'e  disease,  however  olight, 

SreHHure  might  teinpurarily  iucrease>  the  kidney  trouble,  and  pro- 
uc«  convubioiiB;  md  heiiw  it  was  snfe  prnctiCQ  to  remove  prea- 
•uro  in  all  caAee  by  putting  the  patient  iu  a  prone  positioii. 
The  result  proved  how  much  nas  due  to  presaure  of  the  super- 
ittoumhent  tumour  or  child. 

Dr.  UaTEs  ipoko  of  the  treatment  of  such  cases.  Coueidcnuf; 
the  gnire  danger  the  woman  was  incurring  (indeed,  the  daujjur 
increased  generally  as  the  gestation  advanced — at  atl  events  this 
was  so  in  later  months),  he  thought  tlia-t  prematuvo  labour 
should  be  bruiiglit  about  much  earlier  than  was  cuetomnry.and 
not  infrequeully  artificial  abortion.  The  fa>tu«'s  life  wag  gene- 
rally compromised,  it  not  seldom  died,  or  was  expelled  too  young 
to  survive,  Pronounced  albuminuria  should,  lu  hm  opinion, 
always  raise  the  quesliou  of  early  t«rmiiiHtton  of  thi^  gestatiou. 
In  the  present  series  of  four  <;as«s  one  mother  had  diod,  in  two 
tbu  albuminuria  had  continued,  and  one  child  had  died. 

Dr.  KoREitCKs  said  that  any  woman  with  Bright'))  disease  in 
any  form  might  b«coin<^  pregnant,  uud  that  when  she  did  ho  she 
ran  tlio  risks  of  rooal  diseaae  hcsidea  those  of  preguacicy.  She 
might  have  eclamp*ia,  and  without  eclnmpiia  ihe  might  have 
dropsy,  retinal  and  other  vascular  changes,  and  coma.  He  gave 
details  of  two  caseo  of  Dr.  Galabin'a,  iu  one  uf  which  the  patient 
had  retinal  changes  aud  optic  neuritis,  and  in  another  suppres- 
siou  of  urine  and  coma.  Both  died,  and  at  the  pOHl-uiortem 
examination  the  kidneys  were  found  to  be  respectively  of  the 
large  «bite  and  small  granular  types.  In  neither  instance  waa 
there  any  fit.     He  asked  w  hether  any  difterenccs  in  regnrd  to  the 

auaotity  and  quality  of  the  uri-a  and  albumen  had  been  found  in 
JO  pruetnt  Bcrtoe  of  caecs,  eoni|iurcd  wilh  the  fornuT  scries,  to 
'Warrant  any  concluHiou  as  to  the  caudal  relationship  to  fits.  lie 
thought  that  tbe  nervous  eystem  played  an  important  part  in 
tins  production  of  tilD,  and  iu  the  prcM^nt  aenen  only  one  patient 
was  Niugle,  aud  at  she  was  n  ttocuudipura  it  could  be  iutagiued 
that  she  was  not  so  purturlu'd  mentally  as  shu  would  huvu  been 
had  it  been  her  first  prtgnaucy.  In  tbe  other  three  cases  there 
waa  no  mention  made  of  mental  shock. 

Mr.  Albj,x  DouA^r  ubaerved  that  there  appeared  (o  bv  three 

VOL.  XXXll.  '^b 


PRKdNAKCT    WITH    DKIGHt's    1I1BEARE. 


diaensofl  clinically  ttistiuct :  (1)  nlbumiuum  associaicil  witb 
ovariiiu  aui)  oilier  alxlominul  tumours,  (a)  tlie  albuminuria  of 
pregnaacy,  and  (3)  true  Bright'a  discaae  coniplwfttiog  abdo- 
niinal  tumour  or  pregnancy.  Of  tie  first,  he  liiwl  seen  doaena 
of  eases.  The  urine  was  uaually  of  high  epecific  gravity,  and 
th«  amount  of  albumen  oousiderable,  always  disappeariog  after 
eucceBsJ'ul  reniovali  of  tbe  tumour.  EdHiupsia  nnTer  oCcuiTfid ; 
uever  ia  the  annals  of  tbe  Samaritan  Iloapita!  bad  any  case 
of  the  kind  be«n  recorded  where  fitu  took  place  wlien  the 
tumour  grew  very  large,  or  after  a  big  tumour  or  many  gnlloas 
of  fluid  had  beeu  removed,  Tlie  second  form  wna  oltcsn  anao- 
ciatcd  with  eolampsia.  Tbe  third  form  of  necessity  pxiKt«d  in 
some  casetF,  eince  Bright's  disease  was  so  commuD.  Mr.  l>onu 
bad  for  many  years  watched  a  rase  of  this  kind.  The  patient 
was  all  tbu  better  for  ovariotomy,  which  be  performed  in  Decem- 
ber. 1SSj3,  and,  though  wenlt,  remained,  wlieu  lail  awn,  several 
yearii  afterwards,  free  from  any  eign  of  nephritia.  He  bad 
observed  siitiilar  cases  in  tbe  wards  of  bin  colleagues.  Patients 
Hubjeet  to  Bright's  disease  during  pregnancy  wore  usually  all  tho 
better  for  delirery.  Tet  the  general  eurgcon  dreaded  operatioiu 
unoii  persona  eubject  to  Bright's  diseaae,  and  not  without  rcaaoD. 
Mr.  Uoran  veutured  an  eiplauatinn  of  this  curiouB  fact.  After 
amputation  of  n  limb,  or  ligature  of  a  large  artery,  a  patient  with 
Bright's  disease  was,  for  tbe  time,  all  tbe  wor«*  fortbc  operation, 
aud  therefore  in  greater  danger  than  before.  The  ojMjratioD  did 
not  inButnce  the  kidiieya  in  any  favourable  mrtnner,  and  pro- 
bably forced  more  vrork  tipun  those  diecaflftd  organs.  Alter  the 
taking  away  of  a  bulky  tumour,  or  tbe  birtb  of  a  fottus,  the 
patient  was  all  tha  better,  since  a  very  grave  complication, 
directly  influencing  the  dieeaaeil  kidneys  was  removed. 

Dr.  GRiFHTn  stated  that  this  was  especially  a  Biibjeet  in 
which  obstetricians  needed  the  help  of  pbysicianf,  particularly  of 
those  who  made  a  special  etudy  ofkidney-dieeBses.  There  were 
few  subjects,  except  perhaps  iililegmasia  dolene,  needing  more 
information  as  to  their  natural  course,  and  Dr.  Herman's  con- 
tributtona  were  amongst  the  ino^t  valuable.  He  criticiiud  tho 
luc  uf  tbe  term  Bright's  dini^ase,  be^'auav  our  knowledge  of  the 
dtsease  of  the  kidney  was  too  uDHuliftfactory,  aud  be  thought  an 
indefinite  term,  aucb  as  the  "reual  aSection  "  of  pregnancy  and 
parturition  was  free  from  anch  objections,  Colinheiai's  lectures 
on  pathology,  now  in  progrosn  of  translation  and  publication  by 
tbe  Sydenham  Society,  were  valuable  in  relation  to  this  subject. 
Dr.  Hebman  said  that  eomc  of  tbe  questions  asked,  although 
interesting  and  important,  were  outside  the  ncope  of  bis  paper. 
He  bad  made  no  attempt  to  draw  general  concluiions  as  to  tho 
courae  of  neplmtis  in  pregnancy ;  as  to  tho  frcnuoncy  with  which 
renal  disease  in  prugu&ucy  persiRted  after  delivery  ;  as  to  the 
cauBo  of  eclampBJu,  or  the  relutiou  between  Brigbt's  disease  and 


rBBONANCY   WITH    BRIQHT  8   DI5BA8K. 


85b 


cvlampain.  Oae  speaker  hud  aeked  oe  to  wlmi  nav  mcaut  b; 
"  Bnf;ht.'e  diseaae."  Au  tminent  Hueceseor  of  Dr.  Bright  bad 
said  that  we  ought  to  speak  of  "Bright's  diseases"  rather  than 
"Briglit'a  dieeaae,"  and  be  (Ur.  Herman)  had  used  tiie  term 
ID  the  (^oniprebvDBive  eenee  thus  indicated.  Mniiy  nblc  writers 
DD  obstetrics  regurded  eclampsia  ns  oothiiig  ehe  that:  iirwmi<; 
canvulBiotia  opcurring  as  the  reeult  of  kidntj'-diseoee  io  preg- 
nane}' and  childbed.  There  waa  very  little  evideni;e  eitlicr  tor  or 
againMb  this  view,  which  was  m&iuly  based  on  inferences  drawn 
from  our  knowledge  of  reniil  disease  apart  from  prL^gnaney. 
TbiB  Bi-rica  oE  cnees,  and  otbtre  publisbtrd  in  furm^r  papers,  wi-ra 
an  attempt  to  supply  some  data  tor  the  aolittion  of  itis  problem. 
TheEe  data  were  at  present  too  few  to  permit  general  cunclueioaa 
to  bo  drawn  from  them.  He  did  not  think  that  in  Cfisee  such  &a 
those  which  he  had  reported,  the  albuitiiiiiiria  wan  naimpk  result 
of  prusBure.  Tho  characters  of  the  kiduoy  which  were  the  result 
of  reooua  congestion,  and  the  kind  of  urine  «ocretod  by  snch 
kidnejra  were  well  known, and  llie  urinewaa  ouite  ditTerent  from 
that  of  the  cases  now  reported.  He  had  not  discUBsed  the  treat- 
ment in  the  paper,  but,  as  might  be  gathered  from  the  mode  in 
wliieh  hia  caseo  had  been  treated,  he  agreed  with  Dr.  Hayes  tlmt 
induction  of  labour  was  the  best  course.  He  had  made  uo  inves- 
tigations into  acetouuria  in  pregnauey.  In  a  former  paper,  jnib- 
lishvd  in  vol.  xxix  of  the  '  Trausactioue,'  he  had  cullei:led  all  the 
observiitions  thnt  he  cuuld  Bud  recorded  ou  the  uormul  urcu 
excretion  during  pregnancy  and  lying-in,  and  the  raBults  wero 
ao  coutradititory  that  it  could  not  Se  eaid  Ibat  we  had  any 
definite  knowledge  about  tt. 


3&6 


ON  PLUGGTNa  THE  UTKRUS  IN  SEVBHB  CASES 
OF  POST-PART0M  HEMORRHAGE,  WITH 
NOTES  OP  A  SUCCESSFUL  CASE  * 

By  Arthok  H.  N.  Lbwbbs,  M.D.Lontl.,  M.R.CP.Lond. 

tlSIsrAMt  OBStHIKtO  FUTSICIkK  TO  TUB  LOHllOIt    HWflTAL. 


(Boocived  l^'ebniuy  lit,  18D0.) 

Dii.  Auvakd's  '  Travanx  d'Obst^trique,' piiblislied  last 
year,  contain  an  important  luoungraph  on  "  Tainpynne- 
meiit  Intra-Uterin."  He  reviews  Lbe  liiatoiy  of  tbia 
treatment — plugging  tLe  utema  for  poat-partum.  beeujor- 
rbaj,'e — wbicb  tid  recently  had  fallen  into  diftWC,  and 
assigns  t)ie  credit  of  introducing  it  to  Leroux.  Dc. 
Auvard  quotes  a  passago  from  an  account  of  a  caso  of 
post-partutn  biBmorrbiigG  published  in  Lgpokx'h  work, 
■' Obserratioii  sar  les  pertes  de  sang"  (177ll)  in  support 
of  this  view.  The  quotation  is  a.»  follows:  ''  The  tampon 
introduced  into  the  vh^iuh  came  out  tbe  next  day,  while 
the  patient  was  paBsing-  water ;  that  tchtch  wan  in  the 
womb  waa  only  expelled  on  the  fifth  day — it  was  aoeked 
with  a  puriform  fluid." 

Dr.  Auvard  gives  details  o£  seventeen  recent  cases  in 
which  plugging  of  the  uterus  for  post-partum  haiaior' 
rhage  was  adopted  ;  nine  of  theee  weve  by  DiihrssoDj  two 
by  Fraipout,  one  by  Secheyroa,  and  five  were  by  Auvard 
himself. 

Three  of    the  &eventeen  caseB    diodj   bnt  Dr.  Auvard 

does  not  think  that  auy  oue  of  the  deaths  can  be  aticribed 

to  the  breatmetii ;  for  one  died  of  eclampsia,  one  oF  taber- 

*  Tlie  itbovii  licnding  does  not  nccnnitcl;  represent  the  scope  ortlui  p*p«r, 
«uil  nliould  bitrobccD  u  foElttws; — "On  ii  C«bii  iu  wliicli  the  Utcrn*  iru 
plnggtfA  for  HwiiiorrliaKti  nfl«r  MifearriHge  >t  th«  fourth  montli.  with 
Itvmaikt  oil  plugging  Ihv  UUmt  tor  I'oit-partuiii  Unmonrtiagc "  (Authur). 


OTKftOS   PLDGQBD   FOR   H JIHORRHAOK. 


367 


cnloeis  (two  months  after  delivery),  and  ouly  one  died  of 
septicrouiia ;  iti  this  case,  toOj  immGdiate  perineorrhapliy 
had  been  performed. 

I  read  Dr.  Aavard's  monograph  last  summer   (1889)j 

and  the  retitilts  given  seemed  to  me  so  enconraging  tliat 

'  I  determined  to  try  the  treatment  in  questiun  if  I  should 

meet  with  any  case  of  posfc-p»rtum  hfemorrhage  where  the 

QBual  methods  fniled  to  stop  the  bleeding. 

Followiag  Dr.  Auvftrd'a  classification  to  some  extent, 
eases  of  post-pnrtum  Liemorrhnge  may  be  conveniently 
divided  into  two  classes  : 

1.  Cnacs  whore  the  hiemorrlitigo  is  moderate. 

2.  Cases  where  the  htemorrhtige  is  alarming. 

1.  )Vhere  Ike  hiemorrhage  h  inodvrate,  its  cftuse  may 
be  slight  uterine  inertia  or  some  trrHing  wound  of  the 
vulva,  vagina,  or  cervix.  Apiirt  from  the  use  of  pressure- 
forceps   or    ligatures    to    bleeding    points    that    may   be 

* aooesBible,  caaes  in  this  category  are  usually  successfully 
treated  by — 

Manipal&tion  of  the  uterus  through  the  abdominal  wall. 

The  use  of  hU  aiitieeptic  injections  to  the  vagina  or 
uterns,  and 

The  administration  of  ergot. 

2.  In  tho  other  group  of  capes,  i.  e.  where  the  hnsmoT' 
rhage  %»  alarming,  it  may  be  due  to — 

Great  aterine  inertia,  or 

Some  cxtumnvc  laceration  of  the  uterus. 

In  addition  to  the  means  already  mentioned  for  con- 
trolling the  hffimorrhage,  there  is — 

The  introduction  of  the  hand  into  the  uterus,  and  if 
that  also  fail,  the  only  alternative  hitherto  generally  recog- 
oiaed  has  been  the  apph'cation  of  perchloridc  of  iron  to 
the  endometrium  ;  now,  however,  wo  have  what  appears 
lo  be  not  only  a  safer,  bat  a  more  certain  method  of 
treatment,  viz.,  plugging  the  cavity  of  th9  uterus  and 
vugina  wilk  sonje  irieh  maleriat  £U  iodoform-gauxe. 

The  Dotes  of  the  ca»e  in  which  I  adopted  this  treatment 
are  as  follows  : — Mrs.  M — ,  a  lady  about  25  years  of  age, 


358 


VrSBUS    rtUaOKD   fob   nXMOURDAOB 


Itacl  a  tniscarriag'e  ou  tlie  ercning  of  October  17th,  1889, 
wLou  about  four  tuoiitha  pregnant. 

Sbo  was  an  extremely  nervous  woman,  and  her  medical 
attendant  was  almost  certain  that  all  the  placenta  had  not 
come  away,  but  she  was  bo  difficult  to  esamiue,  tbat  no 
more  was  done  at  tbe  time,  nad  be  hoped  that  the  rest  of 
the  placenta  would  come  away  spontaneously.  However, 
the  next  day  there  w&s  an  extremely  offensive  discbarge, 
and  in  the  evenings  the  patient  had  a  rigor  and  a  high 
temperature. 

I  was  asked  to  see  the  case  on  the  19fch  October,  ubont 
thirty-eix  hours  after  the  miscarriage,  with  a  view  to  a 
thorough  examination  being  made  under  an  anjesthetic. 
Chloroform  was  given  by  Dr.  Hugh  Smith,  F.R.C.S., 
Besidonfc  Accoucheur  at  the  London  Hospital. 

On  examination  the  os  was  patulous,  easily  admitting 
two  fingers;  there  was  a  putrid  mass  (subsequently  found 
to  be  of  the  size  of  a  hen's  egg)  partly  protruding  through 
it,  firmly  attached  at  its  upper  part  to  the  posterior 
uterine  wall.  The  patient  was  then  placed  in  the  litho- 
tomy position,  and  the  uterus  drawn  down  to  the  vulva 
with  a  volseila  ;  as  mncb  as  poflsible  of  the  mass  was 
then  removed  with  the  fingers.  The  rest  was  taken  away 
with  strong  ovnm-forcepe.  So  far,  uothiug  unusual  had 
occnrred.  In  order  to  make  sure  that  the  endometrium 
had  been  thorooghly  cleared,  I  then  gently  scraped  the 
posterior  wall  of  the  uterns  with  Recamier's  curette,  an 
instrument  that  has  a  bliuit  edge,  and  scrapes  without 
cutting.  Some  more  putrid  fragments  of  elot  and  pla- 
centa were  in  this  way  removed.  It  was  at  this  time 
that  alarming  hiemorrhage  suddenly  occurred.  I  imme- 
diately irrigated  the  uterus  with  some  very  hot  iodine 
water,  which  was  at  hand  ready  for  washing  out  tlie 
uterus  at  the  end  of  the  operation.  This  did  not  check 
the  hcemorrhage,  which  waa  so  copious  that  I  felt  eure, 
unless  it  could  be  quickly  stopped,  the  patient  must  die. 
Accordingly  I  determined  to  plug  the  uterus. 

The  nntorior  lip  of  the  cervix  being  steadily  held  with 


AFTKIt    HlSCARRrAOE. 


369 


tlie  ToUellft,  a  long  strip  of  dyy  carbolic  gauze,  aliout  as 
broad  us  Uie  1iau<l,  aud  couaistiug  of  four  thickubssea  of 
tbu  material,  was  carried  up  to  tbe  fundus  with  orum- 
forcepn,  and  blic  cavity  of  the  uterns  was  paolced  ag 
rapidly  as  possible,  ino»t  of  the  packing  being  done  by 
pashiug  up  BuccG38i7e portions  of  the  gauze  with  Recamier's 
cuvette.  The  first  strip  was  not  nearly  long  enough ;  a 
second  was  therefore  knotted  to  its  end. 

Iodoform  waa  freely  sprinkled  on  the  gauze  as  it  was 
being  iueerted. 

The  early  part  of  the  plugging  was  aomowhat  difficalt, 
because,  owing  to  the  largo  quantity  of  blooil  coming 
away,  the  gauze  hocanie  so  slippery  that  it  was  diHicult 
to  avoid  bringing  it  out  as  the  iustruuieut  used  to  push  it  in 
vras  each  binio  withdrawn.  As  soon  as  a  yard  or  so  Lad 
been  pasbed  in  the  process  became  easy. 

The  uterus  and  ragina  were  in  this  way  tightly  packed 
with  carbolic  gaiae,  spriukEcd  with  iodoform,  and  n.  T 
bandage  was  put  on  very  tightly  t-o  prevent  the  plugs 
from  coming  out- 

The  bleeding  was  oompletely  stopped,  aud  the  uterus 
coold  be  felt  easily  in  thu  hypogastriutn,  though  at  the 
time  die  hromorthage  occurred  the  uterus  was  so  much 
rolaxed  that  ita  outline  could  not  be  distinguished. 

The  gftuae  wag  left  in  till  next  day  (twenty-one  hours), 
it  waa  then  removed  aud  the  cavity  of  tha  uterus  washed 
out  with  iodinc-walor.  Antiseptic  vaginal  douches  were 
used  for  some  days  longer.  The  haemorrhage  did  not 
recur,  and  the  patient  made  a  perfectly  satisfactory  ro- 
covery. 

Kemarka. — It  will  be  seen  that  the  only  instruments 
required  for  plugging  the  uterus  are— 

A  voliella  to  hold  tbe  utenis  while  the  plug  is  being 
pressed  in,  aud  a  long  jtair  of  owm'forcejMi  to  carry  tho 
gauze  np  to  blic  fundus. 

Smith's  modification  of  Sima's  speculum  is  aseful,  but 
not  essential,  and  I  found  Recamier's  curette  very  conve- 
venicnt  for  packing  in  the  gauze  after  the  Grst  portion 


860 


UTKRD8    PLlJOaRO    FOK    nA:MORKHiGK 


had  Ijcen  inserted  with  ovum-forceps.  Tlic  curette  bcmg- 
narrower  haa  less  temieuey  to  pull  the  gauze  out  as  it  is 
withdrawn. 

Ah  regards  the  viaieriiil  iieetJ  for  plugging. — Dry  carbolic 
gaua©  sprinkled  wilh  iodcform  (in  coaree  powder}  did 
very  well  in  my  case.  Carbolic  gauze  is  A  stool-er  sub- 
RtflTiee  than  iodoform-gniiKi?,  amJ  therefore  has  the  advan- 
tage that  less  of  it  will  bt'  re(]uii'ed. 

It  is  of  oourse  highly  iinportftnt  to  have  an  ample  supply 
oF  whatever  material  is  to  be  used. 

In  order  to  give  some  precise  idea  of  the  qoantity  of 
o&rbolic  gauze  required  to  Bll  a  given  space,  I  have  triod 
how  much  can  be  jirtsaed  into  a  pint  uienaure.  The 
gauze  used  was  four  layers  thick,  and  uvcrugod  four  inchen 
in  breadth.  It  was  fouud  that  thirty-four  feet  four  inches 
were  easily  eontained  in  tho  mt.'nsin'0. 

If  about  to  plug  the  uttTua  and  vagiua  after  delivery  at 
tertn^  I  should  therefore  tika  to  be  provided  with  not  tegs 
than  four  times  that  quantity — that  in  to  say,  about  forty- 
Bix  yardtt. 

So  far  as  the  data  at  present  before  as  afford  materinl 
for  an  opinion,  I  thiuk  tlint  jilugging  the  litems  and  vagina 
is  an  effectual  treatment  for  many  cas«s  of  poat-portum 
hiemorihage  that  would  otherwise  prove  fatal. 


Dr.  PaiESTLEY  >aid  lie  bad  listmied  with  conaiderable  Interest 
to  the  reading  of  the  paper,  but  lie  could  not  hHp  voudenng 
how  eome  oftliD  obatetrlLNatiK  nf  a  pCLSt  gciiirntinn  wunld  linve 
look«<l  upon  tlic  propoxitioD  to  pluf;  in  poiit-purtuiii  liiDiiiorrhiMfe. 
He  rather  IhoiiHht  that  Buch  mpn  na  Simpson,  KamiibfltljAtii. 
Bi^b\,  aud  Arthur  Farre  would  h^ve  looked  upon  ttie  propoBiil 
with  liorror.au  das  contrary  to  all  estnblislied  principles.  He  could 
nnswur  for  it  Unit,  no  long  time  ago,  a  rnnditlate  tJoCore  the  cou- 
joint  board  who  mftintnined  that  phiggingwaa  the  b^st  treatment 
for  poHt-partum  liicmorrtiage  would  linve  been  regarded  as  an 
unHound  and  unsafe  prai^titioner;  dqi]  if  he  wan  not  mislnkeo, 
tbie  cnndidate  would  hnve  n  bad  qunrter  of  an  hour  at  the 
table  of  some  of  the  present  i-x*mincrB.  The  Society  was 
nlwayn  gla^  to  henr  of  new  nielbodu  of  pmctioe  in  midwifery,  and 
it  wfts  well  tha.t  they  nbould  come  bafore  auch  a  Society  as  the 
Obstetrical,  because  here  the  eubject  could  be  well  threeiied  out, 


AFTER   UiaCARItlAGB. 


361 


and  t]ie  reMOQS  for  and  Agajiist  Tally  deWeJ.  He  tbouglil, 
liowever,  notwilbstaading  wliat  had  been  Htated  in  Dr.  Lewers' 
paper,  and  the  Rutbority  Up  hmi  (|iiol»d  in  fiivour  of  the  pro- 
ceeding, that  t liere  were  radical  objoctionsto  it  ns  n  generil  tnothod 
of  trefttmeut  which  would  need  more  than  a  series  of  illuBtrati?e 
casesi  to  remove.  And  he  might  aay  at  once  that  the  case  given 
by  Ur.  Levers  as  Bncce^aful  in  his  own  practice  was  not  quite  a 
case  in  point.  As  the  patient,  be  uotierstiiod,  wae  only  Four 
montha  preguint,  the  utertis  wiis  but  little  lievelop^d,  and 
plugging  even  of  the  vagina  might  bavo  been  quite  a  legitimate 
method,  because  there  was  no  large  and  eipaneible  uterinecavity 
above  it  for  the  accumulation  of  blood.  (To  plug  the  vagina  at 
tho  ful!  time  would  be  to  iucur  the  risk  of  blood  accuuiulating 
in  the  woml] -cavity ;  and  even  If  none  escaped  from  the  vagina, 
the  patient  might  die  of  the  resoltiag  syncope.)  At  the  full 
term  of  pregnancy  the  womb-cavity  was  so  large  and  so  dilatable 
immediately  after  the  evacuation  of  ile  ci>uteut»,  that  a  very 
large  amount  of  material  would  he  required  tu  pack  it  eSectively, 
and  the  proceea  of  packing  it,  with  bk'ediug  goiu^  ou  the  while, 
would  be  no  easy  matter  either  to  the  patient  or  practitioner. 
Some  idea  might  be  formed  as  to  the  amount  of  material  required 
for  vtiifRog  llie  empty  uteru»,  when  it  was  remembered  that  the 
average  weight  of  a  child  cxpcllpd  was  7  IbR.,  and  tho  plaeentn 
probably  from  I  to  2  lbs.  more.  But  he  thought  the  most 
tterious  objection  wa«  that  the  method  suggested  directly 
oppt)««d,  indood  abeolutety  thwarted,  the  physio)ogii>al  pro- 
ccaa  provided  by  nature  for  eecuring  a  parturient  woman 
from  losing  an  undue  quantity  of  blood  aft«r  delivery.  It  was 
well  known  that  there  was  a  wonderful  mechanism  of  muaculnr 
tibrce  HO  arr&ugcd  round  tb«  open  moaths  of  the  passage  at  the 
placental  spot,  that  when  the  middle  wat  of  the  uterus  began  to 
contract  on  the  separation  of  the  alter-birth,  these  open  mouths 
were  constricted  and  occluded.  Any  tampon,  therefore,  large  or 
small,  in  tho  uterine  eavity  would  preveut  this  mechanisru 
coming  into  play  ;  and  if.  perchance,  it  stopped  hiemorrliage  for 
the  time,  it«  removal  might  be  followed  by  tho  last  cnpt^ll  of 
blood,  which  in  the  much-eihausted  patient  bad  been  said  to  be 
the  cause  of  death.  He  repeated  that,  although  always  glad  to 
discuss  improvements  in  practice,  ho  looked  upon  the  trentmeut 
of  poat-partum  hipmorrhage  by  the  tampon  as  contrary  to  physio- 
logical principle!,  and  an  less  worthy  of  trust  than  other  metnodi* 
which  were  now  employed  for  promoting  uterine  contraction.  So 
he  trusted  that  tho  euggo^tiou  to  adopt  tho  practice  iu  these  daya 
when  there  waa  so  much  desire  for  any  new  thing  would  not 
prove  misehievouB.  In  any  case  he  hoped  it  would  not  reeeive 
the  H&nctiou  of  the  Obt<tetrica]  Society  as  a  general  method  of 
treatment  in  puat-partum  htemorrhAge. 

Dr.  Plattaib  said  that  he  had  no  practical  experience  of  the 


362 


UL'KRUS  PLUOOBD  FOR  BMUORHniOZ 


iDetbod  of  dealing  nitti  uosl-partum  hemorrhage  by  plugging  tbe 
Utoriie.  It  seemed  to  nJin,  however,  that  ihere  were  obvious 
objectioQe  to  this  propiosa],  uulesa  very  cnutiouBly  cfttricil  out. 
Dr.  Priestley  had  very  well  expressed  what  tbeiie  were.  It  was 
an  oid'GBtablitihed  axiom  iu  midwifery  practice  that  the  plug  waa 
uever  applicable  so  li^uf;  as  there  was  any  poeeihility  of  tho 
utertis  dilating  behind  it.  A  neuly  emptied  ulerua  might  veiy 
well  4-uDtaiu  a  I'ntal  uumuiil  uf  bluud  iT  ouly  it«  luwer  Mg-' 
meat  were  Klled  witti  the  plug,  itnd  mni^h  c&re  would  be  rofjuired 
to  prevent  the  posoibility  of  this  oi;curronce.  Dr.  Lewcrs'  wa« 
obviously  Dot  a  eane  of  |]OBt-pAi'tiiin  hseiniorrbage  at  all,  but  one 
of  miacnrring^  with  a  rHaineJ  (itid  putrid  placenta.  Here  diin- 
tittioD  i>f  the  uterUB  was  not  poaiibU',  uud  pluijgiiig  might  be  very 
ueeful.  The  eatne  might  be  said  of  secondnry  puBt-piirtuin 
hiBinnrrhage  during  the  puerperium,  wlieu  involution  hadalrwidy 
purtially  uvcurred.  Iu  a  bud  caae  of  this  sort  which  be  bad  eeea 
Boine  weeks  ago,  lie  iiitendtd  to  try  Ibis  plan,  the  hiemorrliage 
having  outoe  on  »  fortnight  aftur  delivery.  Whilo  waiting  for 
the  iodoform-gauze,  however,  be  used  liot-wAter  douche*  into  the 
uterine  cavity,  which  efteclnally  cout  rolled  tbe  ha-morrhoge.  He 
should  consider  it  do  en«j  uiatter  to  pack  a  large  flaccid  uterus 
imoiedifttely  alter  delivery.  The  burden  the  accoucheur  bud  to 
bear  was  already  BuffiL-ieatly  heavy  ;  it  wnuld  beconio  ititolenible 
if  be  hud  to  carry  about  with  bim  tbe  forly-»ix  yardii  ol  anti- 
aeptie  gauze  which  Dr.  Lewere  estimated  aa  the  <iuiiQtity  likely 
to  be  required.  Dr.  Lenera  was  probably  iiware  from  bis 
dotneslic  experiences  that  the  average  amount  of  gauee  required 
fop  a  liidy's  ball-dreas  was  about  twenty  ya^s.  It  was  lo  be 
hoped  that  medical  tituileiits  iu  a  pnuiu  would  not  quote  him  aa 
an  authority  fi>r  poking  the  ciniivaleut  of  two  and  a  half  ball- 
dreaaea  into  the  uterus  after  delivery.  One  einss  of  hemorrhage 
seomed  to  bim  well  suited  for  this  trcatmeut,  end  tbat  waa  the 
kind  dependent  on  laceratious  of  the  cervix  or  vagina.  These 
had  been  deecribed  by  Godchna  "  bnimorrhagoH  with  a  coiitraeted 
iiterue/'  and  in  tb«m  the  presence  of  a  plug  of  antiseptic  gauze 
would  probably  prove  most  elBcaciouB. 

Dp.  CiliMPNHTB  said  that  he  agreed  witb  Dr.  Priestley  and 
Dr.  Plnylair  that  Dr.  Lewcra'  coae  had  nothing  to  do  with  the 
title  oi'  bitt'  paper.  The  uterus  iit  four  inouthH  is  iiicapablo  of 
daugfrouH  L'xpnnsion.  Uu  f^lt  sure  tboy  mmt  all  bavt?  enjoyed 
Dr.  Pluyfuir's  humorous  picture  of  "The  Bleeding  and  the  U&1| 
Drcea,"  and  be  would  have  lelt  inclined  n  j»rtorj  lo  agree  witb 
both  tbe  former  sjieakers  if  he  had  not  happened  to  read  Dr. 
'DiihrsBon's  paper  in  *  Volt(rnanti'«  .Snrikmluug  kliuieehor  Tor- 
trap*  (No.  347,  1H83,  3.  2}S)0).  Tbis  gives  a  circumstautial 
aniftabulated  report  of  moi'e  than  sixty  cases  so  treated,  giTing 
all  uaeeBuary  details,  sueb  bh  the  nmouat  of  bleeding,  Ibe  effwc 
va  tbe  patiiiut,  Lbs  presence  of  lauc-ratioiiv,  and  tbe  meaaa  pre- 


AFTER   UIBCABBUOE. 


363 


vionsty  tried.  He  thnught  that,  if  the  prcviouB  speakers  read 
that,  they  would  be  obliged  to  coni't-sfl  that  a  new  method  must 
be  added  to  our  list,  and  that  it  must  be  accepted  aei  a  Uiit  reeurt 
instead  of  tli«  daogcroua  injection  of  percrnloriiiie  of  iron.  Tf 
{iliigged  properly,  from,  the  fundu*  dowiiwnrde,  the  uterua  do«8 
not  expand  nbove  thu  plug,  wliich,  on  tlid  coiitrn.rj',  actg  &s  nn 
irritnut,and  cnuDi^s  good  eoutraetinu  and  retrncjtioii  Thevftfjiwn 
is  also  lightlj  plugged.  01'  siitj-Gve  cases  of  severe  pOBt-purtuin 
litemorrhai^e  tlniH  treated,  six  died,  one  oulj  of  sepsis.  No 
"  ball-dreas  "  is  required,  nor  eieii  in  nnliBe[)ticgauie  uoeeasary, 
for  aDV  cleau  iiu«u  cau  be  sterilised  by  boiliug  tor  live  minutes 
in  ft  saucepan  or  kettle  with  the  lid  on,  to  produce  a.  uniform 
temperature  of  212°  F.  or  UK)"  C.  The  (juantity  of  material 
required  is  lesa  tbau  would  be  supposed.  Euglishmeii  are  sup- 
posed to  live  on  nu  ifilaud,  but  Dr.  Diibreaen  stutes  in  IbHD  tliat 
the  injection  of  perL'hlonde  uf  iron  is  regarded  in  England  as  a 
practice  aa  important  as  raccJnation.  This  was  an  instanco  of 
German  insularity,  and  was  at  leaat  twenty  years  out  of  dutOiif 
it  erer  were  true. 

Dr.  Lkitii  Nxpisit,  in  view  of  what  Dr.  Cliampneyn  had  said, 
asked  ae  to  the  ra^iW^n/t;  of  plugging  the  p<«t-partum  uterus. 
The  post-partum  was  a  very  differenti  organ  Irom  the  post- 
abortum  uterua.  In  post-abortutu  case*  the  practice  was  juati- 
Gable,  but  ttiei-e  aocoicd  distinct  objections  to  it  iu  pt>st-partum 
conditions.  Moat  ubstetriciutia  held  that  hxinorrhBge  uftcr 
delivery  waa  immediately  arrested  by  uterine  contraction,  and 
that  vubeequeui  bleedings  were  preveuted  by  retractioa,  Ue 
wished  to  ask  Dr.  Chumpneys  if  he  lielicred  that  an  artificial 
olotling,  uu  tho  top  of  a  plug  of  limited  siztt  as  deeeribed,  uould 
do  more  than  permit  temporary  plugging  ol'  the  uterine  sinuses? 
Did  normal  n-traction  occur  witli  thi«  artificial  clot  inside  the 
utvrus  F  Dr.  Leitb  Nnpier  thought  it  likely  that  the  plug  acting 
aa  an  irritnnt  would  tend  to  produce  coritrnctio]i«  in  a  healthy 
uterus  ;  but,  except  in  those  rare  caaea  in  which  there  was  abeo> 
lutely  no  attempt  at  contraction,  dei>cribcrl  as  uterine  paralysia 
at  the  placenta!  aite,  be  fiiiied  to  see  the  neee«»ity  for  or  advisa- 
bility of  the  procedure.  The  idua  waa  by  no  means  new  ;  the 
treatment  bad  been  suggested  long  ogo,  but  never  met  with 
more  than  very  limited  adoption. 

Dr.  Oeiffith  did  uot  look  ou  this  proeeedin;;na  iu  any  seuso 
Dew.  He  had  been  taught  it  uhcn  n  student  at  the  SuHsex 
County  Hospital  in  1873,  by  a  pwctitioner  who  had  studied  at 
Ouy's  Hospilali  Plugging  the  uterus  was  au  invaluable  method 
for  applying  the  perchloride  of  iron,  nud  of  courve  should  only 
be  used  in  case*  in   which  ordinary  trentmenl  fiiiled  to  ensure 

fermaucat  retraction  uf  the  uterua  and  arr«»t  of  the  htemorrbage. 
le  bad  done  it  in  two  carRes.    Theaei  however,  occurred  before 
he  understood  the  advantages  of  hut- water  injcetiou» ;  since  Ibon 


3G4  DTBRCB    PLVOOKD   FOB    R.SMORBHAOE. 

he  liad  bad  no  necessity  for  uaiog  unytbiag  elae.  Br.  Griffith, 
in  these  cukos,  uaed  strips  of  lint  (clean  linen  rogs  or  di&perB 
couLd  be  uaed  in  caee«  uf  em^rgenc?),  tk«  longer  the  better,  two 
to  three  inches  wide  and  a  yard  long.  Th^se  stripe  t;ould  be 
uaed  dry,  or  might  be  wrung  out  of  a  very  dilute  solution  of 
perclilorideof  iron.  The  nuree  having  douesn,  ehoiild  band  them 
ncnrly  dry  to  the  physii-ian.  He  then  passed  them  up  rapidly 
to  tho  fundus,  takm^  special  care  to  leave  one  end  of  oach  strip 
hanging  iu  the  vugiua,  eo  that  they  may  be  eiiaily  withdrawn. 
\iy  thv  time  n  inasa  the  »\7.e  of  one  or  two  flMU  wus  iiiaertcd,  tbe 
uterus  would  bv  found  no  firmly  eontraotod  thiLt  it  would  be 
impossible  lo  insert  more.  It  was  quite  unnecesaury  lo  plug  the 
vagina.  Tbe  plug  should  be  withdrawn  within  twenty-four  huura. 
Dr.  Griffith  had  taught  this  at  St.  Bartholoinow'a  for  eight  years, 
but  it  would  rarely  be  found  neceaaary. 


[Dr.  LswsBa,  who  was  not  prenent  when  his  paper  waa  read 
anddiMCUBsed,  wished  to  explain  that  It  waa  only  in  those  desperate 
i"a»ett  of  post-partum  hicmorrhage  for  which  the  intra-uterlue 
injectiou  of  perchioride  of  irou  hud  hitberto  been  recumtnonded 
that  he  would  ndviae  plugging  of  the  ul  erine  cavity.  He  regarded 
it  only  as  a  last  rcBOuree  when  all  the  usual  means  failed  to  atoji 
the  bleeding.  Gernrnn  and  Prcncli  statistics  seemed  to  ahow 
that  pluggiug  in  ouch  canes  wae  much  lesK  dangerous  than  tho 
iritrn-uterine  injection  of  perchloride  of  irou,  and  at  least  equally 
cirK'ttoioiie.] 


DECEMBER  8rd,  1890. 
Alfred  L.  Galabin,  M.D.,    President,  ia  the  Chair. 
Preseat — 41  Fellows  and  5  Visitors. 

Books  wore  presentecl  by  Dr.  Bmxton  Hicks,  Dr.  Leith 
Napier,  the  Clinical  Society  of  Londou,  tiud  thf  Mcdicul 
aad  Chirnrgicul  Faculty  of  the  State  of  Maryland. 

A.  W.  Mayo  Robson,  F.R.C.S.  (Leeds),  wan  duclarud 
admibtud  a^i  u  Fellow  of  the  Society. 

TLo  foUowiog  geutlemeu  were  elected  FcIIowh  ;-^ 
ThuniAS  S.  Allan,  L.K.C.P.  and  S.Ed.  (Tonbridge) ; 
Skene  Keitli,  M.B.,  C.M.Ediri. ;  Edgar  Asbloy  Lubbock, 
L.H.C.P.Loud.;  John  RejTioIds,  M.D.Brux.;  n.ud  l-'rodt-rick 
Sloman,  M.R.C.S.  (Bnghton). 

The  following  gentlemen  were  proposed  for  election  ;— 
Ernest  Dawson,  L.B.C.P.Lond.  ;  W.  E.  Picton  Phillips, 
M.lt.C.S.  ;  and  Frederick  William  Kanndera,  M.H., 
B.C.Cautab. 


THE    BEGISTKATION    OF    MIDWIVES. 

Thb  PicESiDKNT  said  thai,  some  qucstioua  Laving  been 
Mkod  about  thu  uctiou  of  Coancit  in  regard  to  the  pro- 
posed Bill  for  the  Registration  of  Midwivcs,  tbo  Council 
desired  him  to  etate  the  present  position  of  that  matter. 


TI8ICAL  CAf^ULUB. 

During  the  summer  the  Conncil  was  asked  its  advico 
in  reference  to  the  provisions  of  the  bill  then  in  charge  of 
Mr.  Pease.  The  Council  considered  the  hill,  and  BUg- 
gCBttd  a  nuuibor  of  amendments  in  it,  many  oE  which  were 
accepted  by  the  committeo  in  charge  of  the  bill. 

Since  then  the  bill  had  again  been  greatly  tranaformed, 
and  tho  Council  had  not  yet  considered  the  details  of  the 
bill  a<3  now  propuned.  A  special  meeting  woald  be  held 
this  mouth  lor  the  purpose.  Meauwhilo  tho  Council  bad 
deferred  the  question  of  referring  the  Bobject  to  tho 
Society  at  large. 


POLYPOID    IfTOMA    OF    THE    UTERUS. 

By  A.  E.  AusT  Lawkenck,  M.D. 

Dr.  Ausr  Lawbence  exhibited  a  large  myoma  of  the 
uterus  which  had  become  polypoid  and  lay  in  the  vagina, 
compltitely  blocking  the  pelvie,  and  resting  on  tho 
pi^riuffium. 


VESICAL    CALCULI. 

By  A.  K.  A08T  LiwasNCK,  M.D. 

De.  Ackt  Lawrence  oihibited  Bevorai  calculi  which  had 
been  remcived  by  raginal  cystotomy,  lu  &  caae  of  old- 
stantliug  pi'olapKe  vt  the  uterus  and  bluddur. 


CAST    OF    A    LAllGK    VESICAL   CALCULUS. 

By  A.  E.  ArsT  Lawbkscb,  M.D. 

DiL.    Au8T   Lawkenck    exhibited   a   cast  of  a  culculus 
having   as  its  nucleus   a   hair-pin.      This   calculus  com- 


CALODLI  KKOJI  A  CAbB  OP  PBOI.APBB  OF  UTEBUS,  BTC.     367 

plotcly  (illcfl  the  bindder,  and  extended  along  two-tLirds 
of  tho  urotlira..  It  was  removed  by  crusliiug  through  tho 
uruLhra. 


CALCaLI    FROM    A    CAKE    OF    PROLAPSK    OP 
THE    IJTEKUS    AND    BLADDEK. 


By  Pkecy  BoLiTON,  M.D. 

P.  E.  H— ^  aged  42,  was  sent  into  tho  Samaritan  Free 
Hospital  OD  July  12th,  IS90,  with  complete  prolapse  of 
the  uterus  and  pelvic  viscera.  The  displaced  parts  furmed 
a  tumour  as  large  as  a  cocoa-nut,  protnidiug  between  her 
thighs.     This  condition  was  of  eight  years'  duration. 

On  tAking  hold  of  the  mass  lu  frout  it  felt  like  a  bag 
of  marbles,  nnd  it  was  evident  that  the  bladder  contained 
a  auinber  of  calculi.  The  bladder  had  not  bcea  emptied 
for  eight  years,  but  the  urine  had  ovorHowed  from  the 
urethra,  which,  now  that  the  organ  was  prolapsed,  lay 
appermost. 

On  July  14th  Dr.  Percy  Bonlton  replaced  the  viscera, 
and  then  dilated  the  urethra  with  Hegar's  dilators,  the 
patient  being  under  chloroform. 

He  removed  twenty  calculi,  of  which  five  were  of  the 
Bir^  of  a  walnut  and  fifteen  tfau  size  of  beans.  (Three  calculi 
were  exhibited.)  Two  hundred  and  nineteen  more  stonee, 
□ot  unlike  split  peas,  were  either  washed  out  of  the  bladder 
or  passed  in  tho  nrinc  and  counted  by  the  nursoa. 

Tho  bladder  was  douched  with  boracic  lotion  and  tho 
parte  kept  up  with  a  Zwancb'a  pessary.  Tho  next  day 
the  patient  paSHcd  twenty-two  ounces  of  urine  uaturally^ 
and  from  that  time  continued  to  do  80.  The  urine  was  of 
course  alkaline,  and  contained  onc>tcnth  of  albumen. 

The  patient  returned  home  quite  well. 


868 


FCKTU8,   THE 


SUBJECT   OF 
VESICALIS. 


ATRESIA    ANI 


By  W.  K.  Dakih,  M.D.,  B.S. 

This  specimen  was  aii  eight  montLa'  ftctas,  born  in  au 
attitude  of  extrcuit'  njt.ro flexion  of  the  head  aud  truuk, 
but  with  Iho  legs  flcjtod  on  tie  abdomen,  which  was 
hugoly  distended.  It  was  born  of  the  same  paivnta  as 
tbo  t'uituB  with  rctrotloxioQ  and  ectopia  viecerum  desct'ibmi 
at  p.  200  of  the  pTesent  volume. 

Lahour. — The  preaeiitation  was  sihdominBl,  and  the  cord 
Imd  prolapsed.  Dealh  had  oecurred  Home  da_va  before 
birth,  and  the  head  was  very  soft  and  compressible.  The 
preseutation  was  nn  douht  due  to  thesize  aud  inoumprcBsi- 
bilitj  of  the  ahdumeu,  of  which  the  circumference  at  the 
unTel  was  fifteen  inches,  and  the  auterO'postcrior  diameter 
seven  and  a  half  iuchea.  On  the  other  baud,  the  dia- 
meter which  engaged,  namely  that  lying  between  tho 
front  of  the  neck  and  the  tubera  ischii,  was  not  more  than 
BIX  and  a  half  inches,  and  could  bo  very  easily  compreseed 
into  four  aud  a  half  iiicheB  or  Iohs,  the  reduction  being 
produced  by  yielding  of  the  spine  in  the  direction  of  retro- 
flexion (Fig.  1).  Tho  cord,  a  yard  long,  was  wound 
8e?eral  times  rouud  the  neck.  Tho  placenta  was  normal, 
aud  there  waa  no  trace  of  another  fuetuii. 

AUitudif-  vf  child  and  ejitcniat  iliifurvtitwif. — After  birth, 
the  child  reuiaiiiod  in  the  attitude  in  which  it  was  born, 
and  in  which  it  had  evidently  existed  for  a  cnnsiderablo 
tinao,  as  the  skin  of  the  hack  wa6  put  on  the  stretch  if  the 
poBtnro  was  altered. 

There  was  a  spina  bifida  arieing  from  a  myelocele  in  the 
sacro-lumbar  region,  aud  talipot  varuK  and  ovcrsion  of  tho 
knees.      The   lugs   «ud  feet  were  cluKoly   applied  to  the 


roiTlifl,    THK   aTTBJrCT  OF   ATHKSIA  ASI  VSSICALI*. 

ftbdomen,  and  their  deformity  wan  probably  cansetl    by 
compression  between  the  abdomen  and  the  uterine  wall. 


.^, 


^! 


PiQ.  I,— Showing  nUdoiniiinl  protubfrnucr,  clrrorni!tiM  of  legs  ttnil 
rwt,  and  ■iiiuu  blllilii.  (Tbe  fatal  i*  in  the  mttitnde  iiiA;ntnIn(>(t 
diiricK  Ifthanr.} 

Alimentary  and  genitn-vrinary  ^t/gtema. — There  was 
comploto  fissure  of  the  palate,  but  no  abtiormality  iu  the 
pfaai^nx  or  other  part  of  the  alimenUry  canal  down  to 
the  end  of  the  large  iDtestioe ;  this  wns  fouud  tu  open  into 
the  bauk  of  a  liirge  cyst,  an  will  be  described.  There  was 
no  annSj  nor  oven  a  dimple  repre»enling  it. 

On  opening  the  nbdomea,  tbc  disteDsion  was  seen  (o  be 

VOL.  XXXII.  2*i 


370       PinTDS,    THl   anWBCT   OF   ATBIRIA    AKI    TRSICALrS. 

cnnsed  by  the  large  cyst  nbove  noted.      This  measured  six 
nnd  a  half  inulies   frum  back  to  front,  four  inches  from 


/'A 


~3 


Pio.  2.— Cytt  turnod  d«wiv,  uliowing  (a)  lar^g  Siitwtinc,  openinit 
at  fr-  c.  TiMticlHi.  «'.  Leftviu  Oi^fcretm.  if.  Vmbllicnl  vris.  «. 
Right  iimbilioiil  urtory.  /.  Itigtil  (pi'Tiaiitic  nrtvr^.  y,  Kiiln«T 
witli  nreUr. 


abore  downwards,  and  tlireo  iucliea  ncrosB.  It  was  en- 
tirely above  the  brim  of  the  pelvis,  and  reached  Jronj  the 
front  of  the  lumbar  spine  to  the  umbilicus,  being  attached 
Do  the  latter  by  a  very  short  Htraiid  of  tissue  (one  quarter 
of  an  inch  long),  evidently  the  urachns.  Closely  applied 
to  and  running  along  each  side  of  the  cyst  was  an  um- 
bilical artery  ;  the  right  was  much  larger  than  the  left. 

The  testiclefi  were  very  small,  at  first  glance  they  were 
taken  for  mesenteric  glands.  They  lay  on  the  upper  and 
postero -lateral  part  of  the  cyst,  one  on  each  sidt;.  Their 
ducts  were  scon  to  converge  and  enter  its  wall  about  half- 
way down. 


MfrUB,  THS  BPWBCT  OT   ATRESIA  AM!  TBSECAMa.       371 

On  opentug  tlie  cjsfc  about  fwur  ounces  of  iirino,  with 
flakes  o£  mecoiiiuin  floating'  in  it,  eacaped.  There  were 
four  orifices  on  tho  inoer  surface  ;  three  on  the  posterior 
wrII  (Fig.  3),  and  one  over  the  pelvic  inlet,     Tha  last  led 


L.VMfTIn 


>  8»  t 


^y_ 


Fl«.  3.— Cytt  opciieiH.  ulioiriiifr  praitittlc  carity,  orlAce*  of  InFt 
ureter  and  of  fful,  ami  [JOHiituii  of  urEtlirnl  orilti'e  (intrnial]. 
Urttbnt  li  •ccn  lending  fruui  bladder  lo  (iciiia. 


into  a  very  long  urethra,,  diucIi  stretclied  by  the  elevation 
of  the  eyat.  It  wiis  evident  uow  that  the  cyst  consisted 
of  bladder  plvs  tho  oppor  p&rt  of  the  utlantois,  wbicli 
xhould  have  hecnme  urachus,  and  tho  prontatic  urethra 
which  yraa  expauded  to  form  the  posterior  and  lower  pfirt 
of  the  cavity. 

The  urethra  admitted  a  brifltle  for  a  very  Bhort  distance 
from  both  tlio  vesical  and  poiiila  end.  It  wns  one^and-a- 
quarter  iiichoa  long  from  tho  oy»t  to  tho  pubos,  and  in  the 
iniddlb  oE  its  course  was  almost  but  not  quite  impervious. 

The  other  three  orifices  were  clone  together ;  one  waa 
a  nlit  leading  into  a  blind  sac,  which  probably  rcprcBCuted. 
kbe  prostatic  veMcle,  as  the  fteminal  ducts  ended  cue  on 


372       fVrVij  TUB  SCBJRCT   or  ATBKSIA  ami  VSSICALia. 

ertcli  side  of  it.  Tho  sac  wus  largo  enough  to  contaiD  n 
»ma11  pwi,  its  mucous  mombraue  was  redder  and  roiiglier 
tlmu  tbat  of  the  rest  ui  the  uyst,  and  a  tract  oE  very  thick 
vrliite  mucous  meinbi'aiie  about  half  an  inch  wide  and  two 
inches  long  extended  fnnn  it  to  the  opening  of  tho  aretbra, 
and  was  the  prostatic  mticous  membrane  spread  nut. 

There  was  no  prostnte  gland. 

The  two  orificfs  remaining  were  those  of  the  intestine 
and  tlie  left  ureter.  Of  the  two  the  former  was  the 
emaller,  and  either  readity  itdmitted  a  Ko.  J  catheter. 

There  was  no  right  kidney  or  ureter,  and  the  left 
kidney  was  hydi-onephrotic,  with,  however,  an  undilated 
ureter. 

Both  adi-eual  bodies  were  present. 

All  organs  of  the  body  here  imnientioned  were  normaL 

Mcth<il  of  prodnrtion  of  nbnurmalify. — Together  with 
failure  to  develop  a  cloaoiil  orifice  (which  should  occur 
normally  about  the  fifth  week)  the  lumen  of  the  gut  had 
remained  coutinnous  with  tie  cavity  of  the  allaatoia,  and 
the  contents  of  the  bowel  were  evacuated  into  this  cavity. 
The  urethra  must  have  been  incompletely  developed,  and 
the  outflow  of  urine  interfered  with  to  some  extent,  bo 
the  cyst  became  distended,  rising  out  of  the  pelvis  and 
stretching  the  urethra  (membranous  portion)  till  it  was 
nearly  occluded.  The  backward  pressure  would  then  act 
on  the  kidneys,  and  caused  in  tbia  case  hydronephrosiaof 
one  and  dieappearance  of  the  other. 

Spina  bifida  is  of  Common  occurrence  in  combination 
with  malformation  of  the  alimentary  tract,  for  rousonn 
now  pretty  universally  accepted. 

The  cause  of  the  talipes  has  been  mentioned. 

The  retroflexion  was  entirely  due  to  the  pressure  of  the 
cyst,  and  disappeared  on  \U  evaeualiou, 

Previi>7ig  occtirrmite  in/amUif  of  an  allied  form  of  winn- 
gtroeitf/. — All  interesling  feature  of  tho  case  wm  that  the 
f<Btiis  WHS  born  oE  the  same  parents  n.t  another,  the  subject 
oF  retroflexion  of  the  spine,  ectopia  viscerum,  &c.,  shown  in 
itH  fresh  condition  by  the  writer  in  November  of  last  year. 


rcETVS,  THE   SDBJBOT  OF  ATBIBU  ANI   TE8ICALI8.       373 


Fxes.  4  and  4i. — Jiod«  qforigiit  qf  f^normiUitj/. 


¥ta.  i.  — Praviona  to  formation  of  primiUve  cloacal  opening  j  allan- 
tois  atUcbed  to  anterior  wall  of  gut  with  a  continaona  carity. 
0.  t.  Ovary  or  testis.  «.  h.  4*  d.  Wolffian  ttody  aud  dnct.  ur. 
Ureter,    all,  Allanttua.     oL  Ont. 


ii,a. 


Fio.  4a. — Parts  M  developud  in  proent  ipecimen.     «.  a.  Umbilical 
arterj.    g.  Ont.     t.  Teatii.    k.  Kidney. 


S74 


6AB00HA    or    THE    ITTBBDS. 


Wld  tjubscqiicuily  diBsocted  and  described  in  tho  prcsoot 
voluiuu  ()).  200).  Ill  tliis  case  ako  all  the  abuormalittos 
could  he  tniced  tu  u  t'ailuro  iu  dcvelopmonl  of  tho  hiud 
gut  and  it.3  processes  (see  pp.  212 — 214). 

J>r.  HonitoCKii  mentioned  a  cane  iu  uincli  them  wna  atr««is 
of  rectum,  vagiua,  and  uretbra  in  a  female  child.  Tlio  bladder, 
utcru»,  aud  bowrl  formed  Ihroo  di^ttended  CAvitiea  cBuaini;  so 
much  dyntoi^ia  ufCer  the  delivery  of  the  bend  ibat  the  uterus  rup- 
tured and  the  patient  died.  The  fcetue  waa  dissected  curefullyi 
by  Mr.  Turgett,  and  waa  now  in  the  museum  at  Ouj'e  Uoapital. 


PAPILLOMATOUS  OVARIAN  CYSTS  KKMOVED 
DUKING  THK  FOURTH  MONTH  OF  PREG- 
NANCY. 

By  W.  A.  Mkbkdith,   M.B.,  CM. 


SAUCOM^V    OF    THE    UTEHUS    REMOVED    BY 
VAGINAL  HYSTERECTOMY. 


By  W.  J.  Gow,  M.D. 

Till;  patient  was  a  womac,  aged  49.  Showas  admitted 
into  the  Metropolitan  Free  Hospital  compiaioing  of  uterine 
ho3moiThngG.  A  soft,  friflhlp,  peduncnlatod  maee,  aa  big  as 
a  largo  orange,  was  found  projootiug  into  the  upper  part  of 
tho  vagina.  Its  stalk  truuld  be  traced  up  through  the  in- 
ternal OB.  This  mass  was  removed  with  aii  ecraseur.  A 
few  weeks  later  the  entire  uterus  was  removed  through  the 
vagina.  The  broad  ligamenta  were  secured  with  silk 
ligatures.  The  patient  made  an  excellent  recovei-y.  The 
growth,  which  praved  (o  be  u  Ijuipho-sarcoma,  originated 
ia  tho  wait  ^f  tho  uterine  cavity  ulose  to  thuoriHce  o£  the 
left  Jallepiau  tube. 


37o 


RUPTURED     UTERUS     OCCURRING     DURING 
LABOUR  AND  AFTER  EXTERNAL  VIOLENCE. 

By  John  Phillipsj,  M.D. 

Thk  pntient,  aged  S7,  was  tlio  moblier  of  fcen  children, 
aud  bad  bad  no  mincaTTingas;  alt  her  previous  laltotirs  liad 
been  quite  normal  and  easy,  tbe  vertex  preseutiog  in 
©very  case. 

Ou  the  evening  of  Jtily  llth,  1890,  her  labour  being 
uearly  due.  Hie  was  violently  kicked  in  the  right  groin  by 
her  husband,  who  was  intoxicated  and  was  wearing  nt  thu 
tiaie  heavy  bob-nailed  boots.  She  became  sick  and 
5unt,  aud  was  in  couslderablu  pain  during  the  whole  night. 

Twelve  hours  after  the  uHsault  her  labour  came  on  ; 
everything  progree&ed  well  until  y  p.m.,  when  she  com. 
plained  of  considerable  tearing  pain  in  the  lower  abdomen 
accompanied  by  a  sen&ation  of  fuintneas.  Soon  afterwurda 
the  paiuft  became  k-gs  frequc-ut ;  tlio  presenting  breeeb  nut 
advancing,  and  tbo  abdominal  pain  being  constant,  I  was 
asked  to  80©  her.  1  found  an  extensive  purple  bruise  in 
tbe  right  groin  j  the  patient  was  in  a  eold  BWeal,  her 
face  Bslieu  coloured,  with  a  nmnll  but  regular  pulse  uf 
130  per  minute.  Tbe  breech  was  presenting  niid  lying 
on  the  perineum.  Tbe  pains  occurred  at  intervale  ;  they 
wore  very  feeble  in  character,  and  appeared  to  have  no 
effect  on  the  advance  uF  tbe  presenting  part. 

1  delivered  aa  rapidly  a«  possible  by  passing  a  silk 
handkerchief  ovcT  the  right  thigh  by  meous  of  n  cupper 
wire.  Extraction  waa  quite  caay.  On  pa«l^ing  my  band 
into  tbe  vagina,  I  found  a  nearly  transverse  rent  anteriorly 
in  tbe  genital  c&nal.  Several  loops  of  intestine  could  be 
distinctly  made  out. 

I  expressed  the  placenta,  and  after  injecting  the  patient 
with  etber  eubcutaueuuslyj  went  away  to  procure  assiftl- 


376 


ItUll'UIUiD    Ul'KKUS. 


ance  anil  iTie  nece&sary  instrumeDts  Eor  lApBrotomy,      Onj 
my  rotiiru,  liowc7er,  she  was  pulseleee  and  uioi-ibuudi  auc 
died  sLortly  a.fterwarda. 

Pvet-mortvut. — The  abdooien  wa8  enormously  distondud  j 
there  wns  weH-tuarked  emphysema  of  the  abdouiinftl  wall 
and  8ubp&ritoueHl  tiesuee.  More  tliau  two  quarts  of 
blood  in  a  fluid  state  with  clot  were  remuvod  fryin  the 
posterior  cul-do-sac.      The  blaJder  was  uninjured. 

TL(!  uturuH  after  removal  showed  an  obliqne  tear  four 
ttutl  a  half  inches  loug  anteriorly  and  to  the  right,  tbrongb 
the  lower  &Bgineut  ;  the  rupture  through  the  tissues 
was  complete.  The  uterine  tissue  elsewhere  was  qaibe 
healthy. 

It  WHS  coucladed  that  the  kick  had  lacerated  eome  of 
the  uterine  fibres,  and  that  complete  rupturo  cneDod  with 
labour. 

Dr.  Phillips  had  exhibited  this  spoeimeu  for  throe 
reason B :  (1)  Tlia  rarity  of  rupture  at  this  &ite.  (2)  The 
uiiii»uul  causo  oF  the  rujitute,  (tiiuilar  somewhat  to  the 
lo-called  "  catt]t;-horn  "  ruptuivs.  (3j  The  questioDg 
arising  medic«<tegnlly  from  such  a.  case. 


377 


NOTE  ON  THK  OPERATION  FOE  RESTOUING 
THE  PERINKAr.  HODY  IN  COMPLETE  KUP- 
TUHE    01''    THE    FEMALE    PERINEUM. 

By  A.  E.  Au8T  LiWKBWcK,  M.D. 
(UecoWed  Marrli  BOth,  1890.) 

Uaviko  Operated  on  thirty  caaes  of  complete  rupturu 
of  the  female  perineum  I  &m  induced  to  briog  before  this 
Society  what  I  consider  to  both^cliief  puinta  wliich  must 
be  nttcndoU  to  in  order  to  ubtaiu  sutcess. 

Twonty-oigbl  of  ray  cases  sueceodcd  perfectly  at  tbo 
6r«t  oporntion.  The  other  two  wer^  successful  after  the 
Becond  opi>ration.  All  the  cn^cs  nnffered  fi'om  incontinouco 
of  ftBoes  and  innbility  to  roatrain  flatus,  the  niptiiro  iu 
all  being  ooraplotoly  through  the  lower  portion  of  tho 
rectum.  Is  all  the  operatiuu  was  au  absolute  ueco8i«ity. 
Now  the  secret  of  snccestt  in  repikiriug  this  iujury  consiHtit 
in  freeing  the  rectum  from  its  altHchmeiitK  in  its  abnormal 
ttituiklion,  and  in  bringing  it  down  and  fixing  it  in  its 
proper  place. 

The  operation  I  perform  is  that  known  as  ^plittiii^  thu 
septum,  for  the  £rat  idea  of  which  I  was  indebted  to  Mr. 
Laweon  Tait. 

M.  H —  at  her  first  confinement  hud  the  perineum 
ruptured  through  iuto  the  rectum,  with  the  result  of  incon- 
tinence of  fracGH,  &c.  A  local  surgeon  tried  to  reslurB  the 
periDenm,  and  failed  after  two  operations. 

When  I  saw  the  wonian  she  had  a  large  hole  through 
which  I  could  paxs  my  finger  between  the  rectum  and 
vagina,  and  the  parliiilly  restored  perineuui  had  alao  two 
large  boles  in  it. 


378     oritKArtoN  for  BBSTOBiva  the  fbbineal  soor 


I  stit  tbe  remaining  tissues  up,  and  on  passing  my  finger 
deep  down  iu  the  wound  I  felt  some  wire  Boturea  whiolt 
bud  been  tbere  some  uoutlis.  As  oue  step  of  tbe  ope- 
ration I  picked  awuy  with  forceps  aud  scissors  until  I  hi 
removed  ail  these  wire  sutures,  and  then  I  found  I  badi 
80  freed  the  rectum  (that  is  to  a&y,  the  anterior  porlioD  of 
it)  that  I  was  L'uabled  to  draw  it  down  level  witli  the 
Kkin,  and  I  further  found  that  thei-o  was  no  traction  on 
the  bowel^  and  that  alt  I  Iiad  to  do  was  to  pnll  the  lower 
end  of  the  bowel  down  and  back,  aud  n^-n  up  the  perineal 
wound  in  front  of  it.  Tbe  result  whs  perfect  imion  aud 
complete  restoration  of  tbe  periaenm. 

The  BtepB  I  tafets  in  this  operiitioii  are  us  follows ;  I 
operate,  as  a  rule,  three  days  after  a  menstrual  period 
has  ceased.  I  have  the  bowels  made  to  act  welleachday 
for  one  week  prior  to  the  operation.  On  the  day  of  the 
operation  there  is  no  action  Bolicited.  For  one  day 
before  the  operation  and  for  ten  days  after,  only  liquid 
uourisliment  is  given.  Tbe  patient  iu  of  course  kept  tn 
bed.  No  opium  is  giveu.  The  catheter  is  used  every 
eight  hourB.  One  week  after  the  operation  the  bowels 
are  relieved  by  giving  small  and  repeated  doses  of  cou- 
fcctiou  of  senna  and  tiiilpbur,  and  thenceforward  a  daily 
BUition  is  obtatued.  The  »utui-es  arc  removed  on  tbo  tenth 
to  fourteenth  day,  when  the  wound  is  found  to  he  perfectly 
bcnietl  and  the  patient  has  regained  control  of  the 
rectum. 

The  operation  itself  is  done  as  follows:  I  run  the  blade  ol 
a  Rne  pair  of  BcitiHcirs  along  the  Kharp  edge  oF  the  cicatrix 
in  the  recto-vaginal  septum,  and  at  each  end  of  this 
wound  I  carry  tbo  incision  about  one  inch  forward  into 
tbo  labium.  This  Hap  is  now  pulled  forwards  by  two 
pairs  of  Wells's  forceps,  aud  sufficiently  freed  by  a  few 
snips  of  the  Nciasors  ;  thin  now  gives  a  certain  amoant  of 
raw  surface,  The  important  part  of  the  operation  is  now 
to  be  done.  I  take  hold  of  that  portion  of  the  svptum 
left,  after  what  may  be  termed  the  vagiaal  portion  has 
bsGu  carried  forward.      1  rcgiird  this  portion  as  fumisliiae 


IW   OOUrLBTB  fdfTORl 


iiNKUK.    379 


a  new  rectum.  1  take  hold  of  it  iu  tivo  plaCuH  with 
Wells's  forceps,  and  make  a  clean  cut  with  scissors  on 
each  side  backwards  for  oboiit  half  nn  inch,  and  then 
enip  away  iu  jfront  and  to  the  sides,  until  I  enu  bring 
■down  a  complete  tube  to  the  level  of  the  skin  of  tbe 
periucuiu.  When  this  i*i  doiiu  I  dimply  Imvu  thi»  new 
rectum  hold  back  and  sew  up  the  wound  iii  front ;  by  so 
doing  tlie  perineal  body  is  formed  with  the  rectum  onco 
more  in  its  Bormal  position.  I  use  pure  carljol ised  silk  for 
sutures,  and  bury  most  of  tbeni  completely  iu  the  wound. 
In  introducing  the  suture  I  do  not  include  the  skin,  I 
urn  sure  there  is  less  pain  when  tbe  skin  is  uot  iacludod 
in  tbe  sutures.  Also  if  any  swelling;  taUfs  place  iu  tho 
■new  perineal  body,  the  sutures  can  sink  in  a  little  on  the 
ivi'G  uui-face  and  ho  tako  ofl  the  tension  of  the  deeper 
parte.  Before  commencing  the  operation  I  pass  a  piece 
of  sponge  up  tho  rtJCtnm  and  another  piece  up  the  vagina  ; 
these  of  course  are  removed  after  the  operation  i»  finished. 
Tbe  after- tTeatment  is,  as  I  have  already  mentioned, 
exceedingly  Bimple. 

There  arc  ooine  caseB  where  it  is  impossible  to  bring 
down  u  complete  tube,  owing  to  great  lose  of  tissue  ;  then 
I  bring  tbe  rectal  portion  down  as  a  tube  incomplete  in 
front,  torn  in  tbe  raw  surfaces,  while  they  are  still  held 
by  forceps,  and  pasa  my  perineal  satnres  through  these 
flaps.  Thus  tho  tube  is  completed.  I  am  sure  tho  real 
secret  of  eucco&s  lies  in  completing  the  rectum,  and  Hxiug 
it  as  an  entire  tube  behind  tho  new  porinoal  body.  The 
auuK  in  all  my  eases,  directly  the  operation  is  finished, 
bulgcK  tiut  HH  if  afflicted  with  hninorrhoidN,  and  if  a  million 
took  place  immediately,  nothing  could  possibly  enter  the 
perineal  body. 


860 


TGK  PDHHE-STRING  SUTURK :  ITS  USE  IN  COU- 
PLETE  RUPTURE  OF  THE   PERINEUM. 


By  I'SKCY  BouLTON,  M.D.,  M.R.C.P.LoKb., 

BUXBtCIJUr  to  TBS  SUtABlTAM  rBKB  UOsnTAtu 

(Recdv-ed  April  11th,  ISM.) 

{Ahftracl.) 

The  pApvr  dva<;ribee  an  opeiutioii  whicb  the  author  buM  «ui* 
[iIovlkI  sutiL'L'Hftfully  in  aevuuty-lhruB  oasuu  of  L'oinpk'te  rupture 
of  till!  pi!riucuii].  The  method  of  nuiug  the  piirsc-striii}^  vutui^ 
is  expliiiaed.  and  it  is  vUimRti  that  by  menus  of  it  the  Hphiucter 
ojii  is  more  perfectly  reetorcd  than  by  other  methods  of  opera- 
ting. 

A  serieB  of  diu^rama  auuomjiany  the  paper.  The  so-called 
"  itei'iimi!  body  "  is  formed  by  the  clastic  tiseuti  which  uonstitutea 
tbe  at  tac  bine  tits  of  the  posterior  part  of  the  sp]]iiict«r  VAg'inae, 
tog-jtber  witli  that  of  the  two  transverstLkfl  jtcrinci  diuscIch  aud 
tbu  anterior  attachment  of  th«  8))hiai;ter  ^ui. 

The  loss  of  thflsc  attachmenta  by  complete  rupture  is  shown 
iu  Fig.  1. 

The  posterior  va^ual  wall  bus  shortened  bo  &»  to  form  a  tliick 
tungue  at  y,  while  the  sphiQcU-r  luii  ti.nd  trunsv(.'r»Rk-s  [loriiiei 
haye  retracted  behind  the  rectum,  and  the  3pbiti«ter  is  seen 
thiTO  iu  nearly  a  stntigbl  line  forming  niimei'OUH  rugw. 

Fig.  2  repreayuta  the  liimB  o£  inciHion  neeeaaary  for  repair. 
The  touKuc  If  is  diBBeckd  up  to  a  c.  The  audit  of  tin.'  iipbbcter 
are  laid  bare  at  jtb  aud  a  o,  and  the  points  \a  aud  ci>  arc 
oouuected  by  iuciHioui.  The  tiuBUi^s  botwcini  these  letters  arc 
dt'ntided. 

Fig.  3  sliows  tliu  reolul  tear  (v  is  ct.  No.  2)  closed  by  two  gut  • 


THI   POaBE-STBtNa  SUTrGE. 


381 


sutures  tiL'3  in  the  bowel,  Tbt;  Ji»ursL-. string  suture  ift  seen 
[Misaeil  tbrougb  tlie  emls  ot  tbe  ex|Ki8i;<I  aplikiotLir  uiii  and  ap 
the  recto-vwgina-I  wall  as  far  aa  th«  ba.ee  of  the  tongue  T. 

Pig.  4. — The  purse  stniig  iit  tiod,  «liowiiig  tho  cirole  of  the 
sphincter  perf<>ctl;i'  restored,  and  the  three  sutures  arc  in  |ilftco 
for  cloalng  the  perineum. 


Bo  many  operations  for  the  repair  of  the  female  p^ri- 
neam  have  been  described  tliat  some  miglit  helieve  that 
nothing  uew  romaiiic-d  to  bt-  anid  on  the  subject.  Great 
improveuieuts  have,  however,  token  place  withio  the  last 
thirty  years. 

lu  the  days  of  quili-autoree,  slouffhing  of  the  tissues 
and  failures  followed  long  operations  of  a,n  Lour  or  more, 
and  the  period  of  oonvalesoence  frequently  extended 
over  a  month. 

An  opdinarj  perineorrhaphy  can  now  be  completed  in 
ten  minutes ;  tbe  cures  shLiuld  be  lOO  per  uont.,  and  the 
pnlient  need  not  be  coufiiifd  to  her  bed  for  more  than  ten 
days.  Nothing  can  be  more  certain  or  more  perfect  than 
tliis,  and  it  is  only  when  we  come  to  complete  rupture, 
the  tear  extending  through  the  sphincter  aui  into  the 
bowel,  that  there  is  still  room  Cor  discussing  the  methuds 
of  operation. 

I  bolievo  that  many  experienced  operators  not  infre- 
qaontly  fnil  to  reetore  the  power  of  the  sphincter  ani  so 
that  it  will  hold  liquid  foices  and  flatus,  the  reason  being 
that  without  Nuch  a  lever  as  the  purse-Ktring  KUture  it  is 
difficult  to  raise  the  endx  of  the  muscle  to  the  centre  of 
tbe  perineum  and  keep  tliani  there  so  as  to  complete  the 
circle  of  the  sphincter,  which  remains  weak  in  front  even 
when  the  recto-vaginal  wall  ia  perfectly  restored.  Till 
1880  this  was  frequently  my  own  misfortune,  and  it  wan  in 
that  yoartlrat  I  commenced  thu  treatment  of  the  sphincter 
by  the  "  purse-string  "  suture. 

The  operation  a«  practised  by  mewaa  described  by  Mr. 
Albnu  Doron  in  his  "  fiynnecological  Operations,"  but 
verbal  descriptions  imperfectly  convoy  tho  various  steps  of 


sea 


THE    PnBBR'STBlNQ    atnCRI. 


the  oppralioii,  which  is  not  (liSi(iult  or  comph'cated,  ancl  in 
the  wnrHt  ca^ea  can  be  complotrd  under  thirty  minutes. 

Up  to  the  end  of  July,  1889,  I  had  operated  seventy- 
three  times.  In  no  case  has  it  been  necessary  to  repeat 
the  operation,  and  in  only  a  few  has  the  result  bccu  Boy- 
thing  hut  perfect.  Id  Bomo  of  the  earlier  casos  I  found 
the  sutures  cut  from  too  tight  tying,  but  not  80  as  to  en- 
tirely spoil  the  result. 

Tlie  operation,  difficult  to  describe,  is  easy  to  demon- 
strate, and  in  the  al^sence  of  a  subject  I  propone  to  do 
this  by  means  of  diagrams. 

First,  it  is  necessary  to  bear  in  mind  the  anatomy  of  the 
perineeum. 

The  Bo-called  perineal  "  body  "  is  really  nothing  but 
the  iibro-elastic  tissue  at  the  fonrchette  forming  tho 
attnobments  of — 

1,  The  sphincter  iini  in  front. 

2.  The  two  transversalGs  perinei  muscles. 
8.  The  posterior  attachment  ot  the  sphincter  vuginse. 
4.  The  longitudinal   posterior   muscular  tibres  of    the 

vagina. 

When  the  perineal  body  is  completely  torn  through, 
the  transTeraalis  perinei  retract  and  draw  with  them  ths 
two  enda  oE  the  sphincter  ani  behind  the  reotum.  Th«i 
posterior  vaginal  wall  having  lost  its  attachment  shortens 
an  inch  or  more  and  is  seen  as  a  tbickenod  tongue  up  the 
recto-vaginal  wall.     This  is  shown  in  Fig.  1. 

To  repair  ll)i)t  according  to  my  method  so  as  to  bring 
all  the  parts  again  to  the  central  point  where  they  raoac, 
it  is  neceHsary  to  denude  the  parts  as  shown  in  Figf. 
2.  The  tongue  t  is  spht  and  dissected  up  tfl  a  and  c. 
The  lateral  incisions  a  h,  c  n  must  be  carried  back- 
ward far  enough  to  expose  the  ends  of  the  sphincter  ani 
between  D  r,  and  0  d. 

11  the  (more  or  less)  triangular  opening  into  tlio  ractam 
be  large,  it  should  bo  closed  by  two  or  three  gnit  sutures, 
tied  inside  the  rectum,  cut  off  short  and  left.  If  it  be  not 
large  the  purse-string  suture  will  encircle  and  close  it. 


THE   PUBBB-STBIira   BDTDBI. 


383 


Fie.  1. 


Completfl  raptnro. 

1.  Betneted  apUncter. 
8.  RecUl  t6ir. 
T.  VsgiDHl  tongae. 


Pie.  8. 


Ineiuon*  noctMary  for  mtontion  ihown  bj  lettering  >iid  thick  black  lioea. 


884 


THE    PUBSR-BTIIIMQ   BOTOBS. 


Before  stitching  tlie  rectal  tear,  the  recto-vaginal  wall 
13  split,  the  posterior  and  thicker  part  heiiig  iurued  some- 
what backward  into  the  bowel  when  tlio  gut  sutures  are 
tied,  while  the  unterior  portion  lh  disaocted  off  up  to  tbo 
tongoe  IT,  (Fig.  2),  thus  compicting  the  necessary  denn- 
ilation.  The  tougiie  x  is  now  h«Id  ap  by  inoaos  of  a  pair 
of  "  Wells's"  pressure- forceps  and  the  pnrae-string  suture 
id  introduced  in  the  manner  shown  in  Pig.  3.  The 
gat  RutnreM  nre  seen  already  tied  so  as  to  close  the  rectal 
tear. 

The  "purse-string"  sotare  is  now  paBsed,  entering  the 
end  of  the  sphincter  ani  at  one  side,  running  through  the 
recto -vaginal  wall  up  to  the  base  of  the  toug-ue  T,  which 
is  auppoaed  to  be  held  upward  and  forward.  Uere  the 
soturc  crosses,  taking  a  firm  holding  at  the  base  of  the 
tongue,  and  returning  on  the  otiicr  side  and  through  the 
sphincter  aiii  in  precisely  the  same  way  as  before.  Now 
the  "pui'se-string"  should  be  tied,  and  it  will  be  eeon 
that  in  Joiug  this  the  posterior  vaginal  wall  is  drawn 
downwards,  while  the  two  ends  of  the  sphincter  ani  are 
raised  up  to  the  centre. 

Three  silver  sutures  are  now  passed  as  in  any  ordinary 
perineorrhaphy  (Fig.  4).  The  lowest  one  catches  the 
reatored  Hphinoter  ani  and  takes  most  of  the  strain  off  the 
"  purso-etring."  The  upper  one  traiisfixcB  the  tougoc 
Y,  and  the  third  is  placed  between. 

When  tht'se  are  closed  the  operation  ie  completed. 
The  pL'rinenl  btitches  include  a  quarter  inch  of  skin  at 
either  side,  and  t